What are the treatment options for cluster headache management?

Cluster Headache Management

High-flow oxygen therapy (100% oxygen at 12-15 L/min via non-rebreather mask for 15 minutes) and subcutaneous sumatriptan (6 mg) are the first-line treatments for acute cluster headache attacks. 1, 2, 3

Acute Treatment Options

• High-flow oxygen therapy (100% oxygen at 12-15 L/min via non-rebreather mask for 15 minutes) is highly effective, 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, 4
• Intranasal zolmitriptan (10 mg) is an alternative to subcutaneous sumatriptan, though less effective (OR 3.75 lower than high-flow oxygen) 1, 5
• Noninvasive vagus nerve stimulation is effective specifically for episodic cluster headache but not for chronic cluster headache 1, 2, 5

Preventive Treatment Options

• Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache based on the strongest evidence among available options 1, 6
• Verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is commonly used for prevention, though evidence is less robust than for galcanezumab 2, 7
• Corticosteroids are effective as bridge therapy, requiring at least 100 mg prednisone (or equivalent) orally or up to 500 mg IV daily for 5 days 2, 7
• Alternative preventive options include lithium and topiramate when first-line treatments are ineffective or contraindicated 2, 7

Treatment Algorithm

For Acute Attacks:

1. Start with high-flow oxygen (100% at 12-15 L/min via non-rebreather mask) for 15 minutes at onset of attack 1, 3, 8
2. If oxygen is unavailable or ineffective, use subcutaneous sumatriptan 6 mg 1, 4
3. For patients with contraindications to sumatriptan, consider intranasal zolmitriptan 10 mg 1, 5

For Prevention:

1. For episodic cluster headache, start with galcanezumab 1, 6
2. Verapamil (≥240 mg daily) is an alternative first-line option, particularly for chronic cluster headache 2, 7
3. For rapid but short-term prevention (bridge therapy), use corticosteroids (prednisone 100 mg daily or equivalent) 2, 7
4. For refractory cases, consider lithium or topiramate 2

Important Considerations and Pitfalls

• Oxygen flow rates below 12 L/min are significantly less effective than high-flow rates; proper equipment and flow rates are essential 1, 8, 5
• Galcanezumab is effective for episodic but not chronic cluster headache 1, 6
• Monitor for injection site reactions and hypersensitivity with galcanezumab 6
• When using verapamil for prevention, ECG monitoring is recommended due to potential cardiac effects 2
• Corticosteroids should be used as short-term bridge therapy only due to side effects with prolonged use 2, 7
• Greater occipital nerve blocks may be beneficial, but electrical stimulation of the greater occipital nerve is not recommended due to side effects 2
• For patients with episodic cluster headache who cannot tolerate medication, noninvasive vagus nerve stimulation is an option 1, 2, 5