What are the treatment options for cluster headaches?

Treatment Options for Cluster Headaches

For cluster headache treatment, high-flow oxygen therapy (100% oxygen at 12 L/min via non-rebreather mask for 15 minutes) and subcutaneous sumatriptan (6 mg) are recommended as first-line acute treatments, while galcanezumab is the first-line prophylactic treatment for episodic cluster headache. 1, 2

Acute Treatment Options

• High-flow oxygen therapy (100% oxygen at 12 L/min via non-rebreather mask for 15 minutes) is recommended as first-line treatment, with 78% of patients experiencing pain relief compared to 20% with placebo 1, 3
• Subcutaneous sumatriptan (6 mg) provides rapid relief with 49% of patients experiencing pain relief within 10 minutes and 74-75% within 15 minutes 1
• Intranasal zolmitriptan (10 mg) is recommended as an alternative to subcutaneous sumatriptan 1
• Noninvasive vagus nerve stimulation is suggested for short-term treatment of episodic cluster headache 1
• Home oxygen concentrators may be an effective alternative to conventional oxygen tanks, with 31.7% of patients achieving substantial pain reduction at 15 minutes compared to 12.9% with oral zolmitriptan 4

Preventive Treatment Options

• Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache based on the strongest evidence among available options 1, 2
• Verapamil (minimum daily dose of 240 mg) is commonly used for prevention, though evidence is insufficient for a strong recommendation in American guidelines 1, 5
• Corticosteroids (at least 100 mg prednisone orally or up to 500 mg IV daily for 5 days) are effective as bridge therapy until prophylactic treatments take effect 5, 6
• Alternative preventive options include lithium and topiramate 5, 7
• Greater occipital nerve blocks may be beneficial as bridge therapy 5, 6

Treatment Algorithm

1. For acute attacks:

   • Start with high-flow oxygen (12 L/min) via non-rebreather mask for 15 minutes 1, 2
   • If oxygen is unavailable or ineffective, use subcutaneous sumatriptan (6 mg) 1, 5
   • Consider intranasal zolmitriptan (10 mg) as an alternative if subcutaneous administration is not feasible 1

2. For prevention of episodic cluster headache:

   • First-line: Galcanezumab 1, 2
   • Alternative options: Verapamil (≥240 mg daily), lithium, or topiramate 7, 5

3. For bridging therapy:

   • Use oral corticosteroids or greater occipital nerve blocks until preventive therapy becomes effective 5, 6

Important Considerations and Pitfalls

• Oxygen flow rates below 12 L/min may be insufficient for treating cluster headaches; proper equipment and flow rates are essential 1
• Galcanezumab is effective for episodic but not chronic cluster headache 1, 2
• Monitoring requirements for galcanezumab include watching for injection site reactions and hypersensitivity 2
• Common triggers for cluster headache include strong smells such as tobacco, nail polish, or petroleum, which should be avoided during active periods 2
• Neuromodulation techniques (like non-invasive vagus nerve stimulation) should be considered when medical treatments are contraindicated, cause intolerable side effects, or are ineffective 6