What are the treatment options for cluster headaches?

Treatment Options for Cluster Headaches

For the treatment of cluster headaches, normobaric oxygen therapy (100% oxygen at 12 L/min via non-rebreather mask) and subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) are the first-line options for acute attacks, while galcanezumab is recommended for prevention of episodic cluster headache. 1

Acute Treatment Options

First-Line Treatments

• High-flow oxygen therapy: 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes is highly effective for acute cluster headache attacks, with 78% of patients experiencing pain relief compared to 20% with placebo 1, 2
• Subcutaneous sumatriptan: 6 mg provides rapid relief with 49% of patients experiencing pain relief within 10 minutes and 74-75% within 15 minutes 1, 3
• Intranasal zolmitriptan: 10 mg is recommended as an alternative to subcutaneous sumatriptan 1

Practical Considerations for Oxygen Therapy

• Patients should be provided with appropriate equipment to ensure delivery of high-flow oxygen at 12 L/min using a non-rebreather mask 1
• Home oxygen concentrators can be an effective alternative to oxygen tanks, with 31.7% of patients experiencing substantial pain reduction within 15 minutes 4
• Patients typically have warning before a cluster headache attack, so urgent 4-hour installation of home oxygen should be arranged rather than providing a permanent home supply 1

Preventive Treatment Options

First-Line Prevention

• Galcanezumab: Recommended as first-line prophylactic treatment for episodic cluster headache based on the strongest evidence among available options 5
• Verapamil: Commonly used for prevention, though evidence is insufficient to make a strong recommendation 1, 6, 7

Alternative Preventive Treatments

• Lithium, topiramate: Recommended as alternative preventive treatments 6
• Corticosteroids: Effective as bridge therapy until other preventive medications take effect 6, 7
• Greater occipital nerve block: May be considered, though evidence is insufficient for a strong recommendation 6

Treatments Not Recommended

• Implantable sphenopalatine ganglion stimulator: Not recommended for cluster headache treatment 1
• Galcanezumab for chronic cluster headache: Evidence does not support its use in chronic cluster headache 1

Non-Pharmacologic Options

• Noninvasive vagus nerve stimulation: Suggested for short-term treatment of episodic cluster headache 1, 7
• Physical therapy and exercise: While recommended for tension-type and migraine headaches, evidence is lacking specifically for cluster headaches 1

Treatment Algorithm

1. For acute attacks: Start with high-flow oxygen (12 L/min) via non-rebreather mask for 15 minutes 1, 2
2. If oxygen is unavailable or ineffective: Use subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg 1, 3
3. For prevention of episodic cluster headache: Consider galcanezumab as first-line option 5
4. For bridging therapy: Use corticosteroids or greater occipital nerve block until preventive medications take effect 6, 7

Common Pitfalls and Caveats

• Oxygen flow rates below 12 L/min may be insufficient for treating cluster headaches; proper equipment and flow rates are essential 1, 2
• Patients with cardiovascular risk factors should use triptans with caution due to potential vasoconstrictive effects 3
• Regular ECG monitoring is necessary when using verapamil at higher doses for prevention 6
• Galcanezumab is effective for episodic but not chronic cluster headache 1