What are the treatment options for cluster headaches?

Treatment Options for Cluster Headache

For the treatment of cluster headaches, high-flow oxygen therapy (100% oxygen at 12 L/min via non-rebreather mask for 15 minutes) and subcutaneous sumatriptan (6 mg) are the first-line acute treatments with the strongest evidence for efficacy. 1, 2

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, with 78% of patients experiencing pain relief compared to 20% with placebo 1, 3
• Subcutaneous sumatriptan: 6 mg provides rapid relief with 74-75% of patients experiencing pain relief within 15 minutes and 49% experiencing relief within 10 minutes 1, 2
• Intranasal zolmitriptan: 10 mg is recommended as an alternative to subcutaneous sumatriptan 4, 1

Important Considerations for Acute Treatment

• Oxygen flow rates below 12 L/min may be insufficient for treating cluster headaches; proper equipment and flow rates are essential 1, 5
• Home oxygen concentrators can be an effective alternative to oxygen tanks, with 31.7% of patients experiencing substantial pain reduction at 15 minutes 5
• Treatments should be administered as early as possible in the attack for maximum effectiveness 6

Preventive Treatment Options

First-Line Preventive Treatments

• Galcanezumab: Recommended for the prevention of episodic cluster headache (not effective for chronic cluster headache) 4
• Verapamil: Commonly used for prevention, though evidence is insufficient for a strong recommendation 4, 6

Other Preventive Options

• Corticosteroids: Used as bridge therapy until other preventive treatments take effect 6, 7
  • Oral prednisolone or methylprednisolone (at least 100 mg daily, up to 500 mg IV per day over 5 days, then tapering) 7
  • Suboccipital nerve blocks with corticosteroids 6
• Other potential preventives: Lithium, topiramate, gabapentin, and melatonin have shown some efficacy 8, 7

Neuromodulation Options

• Non-invasive vagus nerve stimulation: Suggested for short-term treatment of episodic cluster headache, especially when medications are contraindicated or cause intolerable side effects 1, 6
• Occipital nerve stimulation: May be considered for treatment-refractory chronic cluster headache 6

Treatment Algorithm

1. For acute attacks:

   • Start with high-flow oxygen (12 L/min) via non-rebreather mask for 15 minutes 1, 3
   • If oxygen is unavailable or ineffective, use subcutaneous sumatriptan 6 mg 2
   • Consider intranasal zolmitriptan 10 mg as an alternative 4

2. For prevention during cluster periods:

   • For episodic cluster headache: Consider galcanezumab as first-line 4
   • Consider verapamil (at least 240 mg daily) for both episodic and chronic cluster headache 6, 7
   • Use corticosteroids as bridge therapy until preventive medications take effect 6, 7

Common Pitfalls and Caveats

• Galcanezumab is effective for episodic but not chronic cluster headache 4
• Oxygen therapy requires proper equipment and adequate flow rates (minimum 12 L/min) to be effective 1, 3
• Medication overuse can occur with frequent use of acute treatments, potentially worsening headache patterns 4
• Surgical procedures for cluster headache require further scientific evaluation before being widely recommended 7