What are the treatment and prevention options for cluster headaches?

Cluster Headache Treatment and Prevention

For cluster headache treatment, subcutaneous sumatriptan (6 mg) or high-flow oxygen therapy (100% oxygen at 12-15 L/min via non-rebreather mask for at least 15 minutes) should be used as first-line abortive treatments, while galcanezumab is recommended for prevention of episodic cluster headache only. 1, 2

Acute Treatment Options

• Subcutaneous sumatriptan (6 mg) is recommended for the short-term treatment of cluster headache attacks, with clinical trials showing pain relief in 74% of attacks within 15 minutes compared to 26% with placebo 3, 4, 5
• Intranasal zolmitriptan (10 mg) is an effective alternative first-line option for acute treatment 3, 1
• High-flow normobaric oxygen therapy (100% oxygen at 12-15 L/min via non-rebreather mask for 15 minutes) is strongly recommended as a first-line abortive treatment with several advantages: no side effects, no contraindications, and can be used multiple times daily 3, 1, 2, 6
• Recent research shows that home oxygen concentrators can be an effective alternative to oxygen tanks, with better pain relief than oral zolmitriptan and no reported adverse events 7
• Non-invasive vagus nerve stimulation is suggested for the short-term treatment of episodic cluster headache when pharmacologic treatments fail or are contraindicated 1, 2

Preventive Treatment Options

For Episodic Cluster Headache

• Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache (weak recommendation for) 3, 1
• There is insufficient evidence to recommend for or against verapamil for the prevention of episodic cluster headache, though it is commonly used in clinical practice (at least 240 mg daily) 3, 1

For Chronic Cluster Headache

• Galcanezumab is not recommended for prevention of chronic cluster headache (weak recommendation against) 3, 1
• There is insufficient evidence to recommend for or against verapamil for chronic cluster headache prevention 3, 1
• For treatment-refractory chronic cluster headache, occipital nerve stimulation may be considered based on clinical trial data 8

Bridging Therapy

• Corticosteroids (oral prednisolone or suboccipital injections) are commonly used as bridge treatments until preventive medications take effect 8, 9
• These treatments help manage symptoms during the period when long-term preventives are building efficacy 8

Important Considerations and Monitoring

• Monitor frequency of sumatriptan use to prevent medication overuse headache 2
• Implantable sphenopalatine ganglion stimulator is not recommended for cluster headache treatment (weak recommendation against) 1
• The efficacy of subcutaneous sumatriptan has been demonstrated in long-term use without evidence of tachyphylaxis over 3 months of treatment 5
• For patients with frequent attacks, consider preventive medications alongside acute treatments to reduce attack frequency and severity 2, 8

Treatment Algorithm

1. For acute attacks:

   • First-line: Subcutaneous sumatriptan 6 mg OR high-flow oxygen (100% at 12-15 L/min) 3, 1, 2
   • Alternative: Intranasal zolmitriptan 10 mg if first-line options are unavailable or contraindicated 3, 1

2. For prevention:

   • Episodic cluster headache: Galcanezumab 3, 1
   • Chronic cluster headache: Consider verapamil (despite insufficient evidence) 1, 8
   • Bridge therapy with corticosteroids while waiting for preventive medications to take effect 8

3. For treatment-refractory cases:

   • Consider neuromodulation options such as non-invasive vagus nerve stimulation or occipital nerve stimulation 1, 8