What is the treatment for cluster headaches?

Treatment of Cluster Headaches

For the treatment of cluster headaches, subcutaneous sumatriptan (6 mg), intranasal zolmitriptan (10 mg), and normobaric oxygen therapy are recommended as first-line acute treatments, while galcanezumab is suggested for prevention of episodic cluster headache only. 1, 2

Characteristics of Cluster Headaches

• Cluster headaches are characterized by severe unilateral pain in the trigeminal distribution with ipsilateral cranial autonomic features and a sense of agitation 3
• They involve severe unilateral, supraorbital, or temporal pain lasting 15-180 minutes with features such as lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, and eyelid edema 1
• Attacks frequently occur at night, awakening patients from sleep, and unlike migraine sufferers, patients with cluster headache often pace about during attacks 4

Acute Treatment Options

First-Line Treatments

• Subcutaneous sumatriptan (6 mg) is recommended for short-term treatment of cluster headache attacks 1, 2
• Intranasal zolmitriptan (10 mg) is recommended for short-term treatment of cluster headache attacks 1, 2
• Normobaric oxygen therapy (100% oxygen at flow rates of at least 12 L/min for 15 minutes) is recommended for acute treatment 1, 2, 5

Second-Line Treatment

• Noninvasive vagus nerve stimulation is suggested for the short-term treatment of episodic cluster headache 1, 2

Preventive Treatment Options

Episodic Cluster Headache Prevention

• Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache with the strongest evidence among available options 2, 5
• Verapamil (at least 240 mg daily, with maximum dose depending on efficacy and tolerability) is commonly used, though evidence is insufficient according to recent guidelines 2, 5

Chronic Cluster Headache Prevention

• Galcanezumab is not recommended for chronic cluster headache prevention (weak recommendation against) 1, 2
• There is insufficient evidence to recommend for or against verapamil for chronic cluster headache prevention 1, 2

Other Preventive Options

• Corticosteroids (oral or suboccipital injections) are effective as bridge treatments until other preventive medications take effect 6, 5
• Lithium and topiramate may be considered as alternative preventive treatments 5
• Melatonin has some evidence supporting its use as a preventive treatment 3, 7

Treatments Not Recommended

• Implantable sphenopalatine ganglion stimulator is not recommended for cluster headache treatment (weak recommendation against) 1, 2

Treatment Algorithm

1. For acute attacks:

   • First try high-flow oxygen (100% at 12+ L/min for 15 minutes) 1, 2, 5
   • If oxygen is unavailable or ineffective, use subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg 1, 2
   • Consider noninvasive vagus nerve stimulation for episodic cluster headache 1, 2

2. For prevention:

   • For episodic cluster headache: Start with galcanezumab 2, 5
   • For chronic cluster headache: Consider verapamil (at least 240 mg daily) despite limited evidence 2, 5
   • Use corticosteroids as bridge therapy while waiting for preventive medications to take effect 6, 5

Common Pitfalls and Caveats

• Misdiagnosis of cluster headache as migraine can lead to inappropriate treatment strategies 1, 3
• Galcanezumab should only be used for episodic cluster headache, not chronic cluster headache 1, 2
• Oxygen therapy requires specific parameters (high flow rate of at least 12 L/min and 100% oxygen) to be effective 2, 5
• Verapamil, while commonly used, has insufficient evidence according to the most recent guidelines 1, 2
• Implantable devices should be avoided as first-line treatments due to weak evidence against their use 1, 2