What are the treatment options for cluster headaches?

Treatment Options for Cluster Headache

High-flow oxygen therapy and subcutaneous sumatriptan are the first-line treatments for acute cluster headache attacks, while verapamil and galcanezumab are recommended for prevention. 1, 2

Acute Treatment Options

• High-flow oxygen therapy: 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes is highly effective as a first-line treatment for acute cluster headache attacks, with 78% of patients experiencing pain relief compared to 20% with placebo 2, 3

• Subcutaneous sumatriptan: 6 mg provides rapid relief with 49% of patients experiencing pain relief within 10 minutes and 74-75% within 15 minutes of injection 2, 4

• Intranasal zolmitriptan: 10 mg is recommended as an alternative to subcutaneous sumatriptan for acute cluster headache attacks 1, 2

• Timing of treatment: Begin treatment as soon as possible after onset of cluster headache attack for maximum effectiveness 4

Preventive Treatment Options

• Galcanezumab: Recommended as a first-line prophylactic treatment for episodic cluster headache based on strong evidence, but not recommended for chronic cluster headache 1, 2

• Verapamil: Commonly used for prevention of both episodic and chronic cluster headache, though evidence is insufficient for a strong recommendation 1, 2, 5

• Other potential preventive options: Lithium, gabapentin, topiramate, divalproex sodium, and melatonin may be effective when first-line treatments fail 5

Treatment Algorithm

1. For acute attacks:

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

2. For prevention of episodic cluster headache:

   • Consider galcanezumab as a first-line option 1, 2
   • Verapamil is an alternative option despite limited evidence 1, 5

3. For prevention of chronic cluster headache:

   • Verapamil is commonly used 5
   • Galcanezumab is not recommended 1

4. For bridging therapy (until preventive treatment becomes effective):

   • Corticosteroids (oral or suboccipital injections) 6, 5

Common Pitfalls and Caveats

• Oxygen flow rates: Rates below 12 L/min may be insufficient for treating cluster headaches; proper equipment and flow rates are essential 2

• Sumatriptan contraindications: Triptans are contraindicated in patients with risk for heart disease, basilar or hemiplegic migraine, or uncontrolled hypertension 1

• Medication differentiation: Galcanezumab is effective for episodic but not chronic cluster headache 1, 2

• Treatment resistance: For patients not responding to standard treatments, consider neuromodulation options such as non-invasive vagus nerve stimulation 2, 6

• Diagnosis confirmation: To exclude structural mimics, patients presenting with symptoms suggestive of cluster headache warrant at least a brain MRI scan in their work-up 7