What are the treatment options for cluster headaches?

Treatment Options for Cluster Headaches

For the treatment of cluster headaches, high-flow oxygen therapy and subcutaneous sumatriptan are the first-line acute treatments, 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 attacks, with 78% of patients experiencing pain relief compared to 20% with placebo 1, 2
• Subcutaneous sumatriptan: 6 mg provides rapid relief with 74-75% of patients experiencing pain relief within 15 minutes 1, 3
• Intranasal zolmitriptan: 10 mg is an effective alternative to subcutaneous sumatriptan 4, 1

Efficacy Data for First-Line Treatments

• Subcutaneous sumatriptan 6 mg demonstrates significant efficacy with 49% of patients experiencing relief within 10 minutes and 74% within 15 minutes of injection 3
• High-flow oxygen therapy has shown superiority over placebo in randomized controlled trials, with 78% of patients achieving pain freedom at 15 minutes 2
• Home oxygen concentrators can be an effective alternative to oxygen tanks, with 31.7% of patients achieving substantial pain reduction at 15 minutes and 57.1% at 30 minutes 5

Preventive Treatment Options

First-Line Preventive Treatments

• Galcanezumab: Recommended for prevention of episodic cluster headache based on strong evidence 4
• Verapamil: Commonly used in clinical practice, though evidence is insufficient for a strong recommendation 4, 1

Second-Line Preventive Options

• Corticosteroids: Often used as "bridge therapy" until longer-acting preventives take effect 6, 7
• Lithium: May be effective for prevention, particularly in chronic cluster headache 7, 8

Treatment Algorithm

For Acute Attacks:

1. Start with high-flow oxygen: 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes 1, 2
2. If oxygen is unavailable or ineffective: Use subcutaneous sumatriptan 6 mg 4, 3
3. Alternative if sumatriptan is contraindicated: Intranasal zolmitriptan 10 mg 4, 1

For Prevention:

1. Episodic cluster headache: Galcanezumab is recommended as first-line 4
2. Consider verapamil: Despite limited evidence, it's commonly used in clinical practice 4, 6
3. Bridge therapy: Consider short-term corticosteroids while waiting for preventive medications to take effect 6, 7

Non-Pharmacologic Options

• Noninvasive vagus nerve stimulation: May be considered for episodic cluster headache when medications are contraindicated or poorly tolerated 1
• Occipital nerve stimulation: May be considered for treatment-refractory chronic cluster headache 6

Important Considerations and Pitfalls

• Oxygen delivery: Flow rates below 12 L/min may be insufficient; proper equipment and flow rates are essential 1, 2
• Treatment selection: Galcanezumab is effective for episodic but not chronic cluster headache 4, 1
• Medication overuse: Monitor for medication overuse headache with frequent use of acute treatments 4
• Route of administration: Due to the rapid onset and severity of cluster headache attacks, non-oral routes (inhalation, subcutaneous, intranasal) are preferred for acute treatment 6, 7
• Timing of treatment: Acute treatments should be initiated as soon as possible after attack onset for maximum effectiveness 3, 2