What are the treatment options for cluster headaches?

Treatment Options for Cluster Headaches

High-flow oxygen therapy (12-15 L/min via non-rebreather mask for at least 15 minutes) is the first-line treatment for acute cluster headache attacks due to its safety profile and effectiveness. 1

Acute Treatment Options

First-Line Treatments

• High-flow oxygen therapy:

  • Flow rate: 12-15 L/min via non-rebreather mask
  • Duration: At least 15 minutes
  • Efficacy: 78% of patients achieve pain freedom at 15 minutes (vs. 20% with placebo) 2
  • Should be started immediately at attack onset for maximum effectiveness
  • Remarkably safe with minimal adverse effects 1

• Subcutaneous sumatriptan (6 mg):

  • Effective alternative when oxygen is unavailable
  • Contraindicated in patients with cardiovascular disease 1

Second-Line Treatments

• Intranasal zolmitriptan (10 mg):
  • Alternative when sumatriptan is contraindicated 1

Preventive Treatment Options

Episodic Cluster Headache Prevention

• Galcanezumab (monoclonal antibody to CGRP):

  • High level of evidence for episodic cluster headache
  • Not recommended for chronic cluster headache 1

• Non-invasive vagus nerve stimulation:

  • Moderate evidence for effectiveness in episodic cluster headache
  • Not effective for chronic cluster headache 1

Chronic Cluster Headache Prevention

• Verapamil (at least 240 mg daily):

  • First-line preventive treatment
  • Requires ECG monitoring before initiation and with dose increases 1, 3

• Lithium:

  • Alternative preventive option when first-line treatments fail 1, 4

Additional Preventive Options

• Topiramate
• Greater occipital nerve blocks
• Melatonin
• Gabapentin
• Divalproex sodium 1, 4

Bridging Therapy

• Corticosteroids:
  • Used until preventive medications take effect
  • Typically 100 mg prednisone orally or up to 500 mg IV daily for 5 days 1
  • Can also be administered as suboccipital injections 3

Important Clinical Considerations

Treatment Implementation

• Patients should be educated to begin treatment immediately at attack onset
• Home oxygen should be arranged with provision for urgent 4-hour installation when a cluster period begins 1
• Oxygen concentrators can be an effective alternative to oxygen tanks

Monitoring and Safety

• Regular evaluation of treatment efficacy is necessary to adjust therapy
• Cardiac monitoring is required for patients on verapamil
• Avoid opioids due to risk of dependency and rebound headaches 1
• Monitor for medication overuse headache (headache occurring on 15+ days/month for at least 3 months) 1

Lifestyle Modifications

• Counsel patients to avoid triggers, particularly alcohol 1
• Ensure rescue medication is readily available during cluster periods

Emerging Treatments

Recent research indicates several promising investigational therapies:

• Ketamine
• OnabotulinumtoxinA
• Lysergic acid
• Sodium oxybate 4

For treatment-refractory chronic cluster headache, occipital nerve stimulation may be considered as an invasive neuromodulation option 3.