What is the treatment for cluster headaches?

Treatment for Cluster Headaches

For acute treatment of cluster headache attacks, subcutaneous sumatriptan (6 mg), high-flow oxygen therapy (100% oxygen at 12-15 L/min for 15 minutes), or intranasal zolmitriptan (10 mg) are the recommended first-line options. 1, 2, 3

Acute Treatment Options

• Subcutaneous sumatriptan 6 mg provides rapid relief, with clinical trials showing pain relief in 74-75% of patients within 15 minutes 3, 4
• High-flow oxygen therapy (100% oxygen at flow rates of 12-15 L/min via non-rebreather mask for at least 15 minutes) is highly effective and safe, with studies showing 78% of patients becoming pain-free at 15 minutes 5, 6
• Intranasal zolmitriptan 10 mg is recommended as an alternative acute treatment option 1, 4
• Noninvasive vagus nerve stimulation is suggested for short-term treatment of episodic cluster headache 1, 2

Preventive Treatment

For Episodic Cluster Headache

• Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache based on the strongest evidence among available options 2, 7
• Verapamil (at least 240 mg daily, with maximum dose depending on efficacy and tolerability) is commonly used, though evidence is less robust 2, 4

For Chronic Cluster Headache

• Galcanezumab is not recommended for chronic cluster headache prevention (weak recommendation against) 2, 7
• Verapamil, lithium, topiramate, and corticosteroids may be considered for chronic cluster headache, though evidence is limited 4, 8

Bridging Therapy

• Corticosteroids (at least 100 mg prednisone or equivalent) given orally or up to 500 mg IV per day over 5 days can be used as bridging therapy until preventive medications take effect 4, 9
• Greater occipital nerve blocks may be beneficial as bridging therapy 4, 9

Treatment Algorithm

1. Acute attack management:

   • First-line: High-flow oxygen (100% at 12-15 L/min for 15 minutes) 5, 6
   • First-line alternative: Subcutaneous sumatriptan 6 mg 1, 3
   • Second-line: Intranasal zolmitriptan 10 mg 1, 4

2. Preventive treatment:

   • For episodic cluster headache: Galcanezumab 2, 7
   • For chronic cluster headache: Verapamil (at least 240 mg daily) 4, 8
   • Alternative preventive options: Lithium, topiramate, melatonin 8, 9

3. Bridging therapy:

   • Corticosteroids (oral prednisone 100 mg or equivalent) 4, 9
   • Greater occipital nerve blocks 4

Important Considerations

• Avoid implantable sphenopalatine ganglion stimulator for cluster headache treatment (weak recommendation against) 1, 2
• Oxygen therapy requires proper equipment (non-rebreather mask) and technique to be effective 5, 6
• Monitor for side effects with preventive medications, particularly cardiac effects with verapamil 4, 8
• Physical therapy, aerobic exercise, or progressive strength training may provide additional benefit 1
• There is insufficient evidence to recommend dietary trigger avoidance for prevention of cluster headaches 1