Treatment Options for Cluster Headaches
For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg or high-flow oxygen (100% at ≥12 L/min for 15 minutes), and for prevention of episodic cluster headache, galcanezumab is the first-line prophylactic agent with the strongest evidence. 1, 2
Acute Treatment (Abortive Therapy)
First-Line Acute Treatments
Subcutaneous sumatriptan 6 mg is highly effective, providing headache relief in 70-75% of patients within 10-15 minutes. 1, 3 The FDA label demonstrates that 49% of patients achieve complete pain freedom at 15 minutes, with 75% achieving relief by this timepoint. 3 This represents the fastest and most effective acute treatment option available.
High-flow oxygen therapy (100% normobaric oxygen) should be administered at a minimum flow rate of 12 L/min for 15 minutes. 1, 2, 4 Recent evidence using home oxygen concentrators (connecting two units) demonstrated 31.7% substantial pain reduction at 15 minutes and 57.1% pain relief at 30 minutes, with all treated patients reporting some improvement and 61.3% preferring oxygen over oral medications. 5
Alternative Acute Treatments
Intranasal zolmitriptan 10 mg provides 30-minute pain relief in 62% of patients (NNT 2.8), making it an effective alternative when subcutaneous administration is not feasible. 1, 6 Oral zolmitriptan 5 mg is less effective than oxygen therapy, with only 12.9% achieving substantial pain reduction at 15 minutes. 5
Intranasal sumatriptan is another option, though subcutaneous administration remains superior for speed and efficacy. 7, 6
Prophylactic (Preventive) Treatment
First-Line Prevention
Galcanezumab has the strongest evidence for prevention of episodic cluster headache and should be considered first-line prophylaxis. 1, 2, 4 However, there is a weak recommendation AGAINST galcanezumab for chronic cluster headache, so this distinction is critical. 1, 2
Transitional (Bridging) Therapy
Corticosteroids (prednisone at least 100 mg orally or up to 500 mg IV daily for 5 days) provide rapid prophylactic effect while waiting for maintenance therapy to become effective. 7, 4 This bridging approach is essential when initiating slower-acting preventive medications.
Greater occipital nerve block can also serve as transitional therapy. 7, 4
Maintenance Prophylaxis
Verapamil at a minimum daily dose of 240 mg (titrated based on efficacy and tolerability) is the traditional mainstay of prophylactic therapy, though current guidelines note insufficient evidence to make a firm recommendation for or against its use. 1, 4, 8 Despite this equivocal guideline stance, verapamil remains widely used in clinical practice given decades of experience.
Alternative prophylactic agents with evidence include lithium, topiramate, gabapentin, divalproex sodium, and melatonin, though these are generally considered second-line options. 7, 4, 8
Neuromodulation
Noninvasive vagus nerve stimulation is recommended for short-term treatment of episodic cluster headache (but not chronic cluster headache). 1, 4
Implantable sphenopalatine ganglion stimulators have a weak recommendation AGAINST their use due to unfavorable risk-benefit profile. 1
Critical Clinical Considerations
Route of Administration Matters
Non-oral routes (subcutaneous, intranasal, inhalation) provide faster and more effective responses than oral medications due to the rapid onset and short duration of cluster attacks. 6 The extreme intensity and quick onset of cluster headache attacks necessitate treatments that work within 10-15 minutes.
Episodic vs. Chronic Distinction
This distinction is crucial for prophylactic treatment selection. Galcanezumab is recommended FOR episodic cluster headache but AGAINST chronic cluster headache (attacks occurring >1 year without remission). 1, 2 Noninvasive vagus nerve stimulation similarly works for episodic but not chronic forms. 1, 4
Common Pitfalls to Avoid
- Do not confuse acute and prophylactic treatments: Oxygen and triptans abort attacks but do not prevent them; prophylactic agents prevent attacks but do not treat acute episodes. 2
- Avoid opioids and butalbital: These are explicitly not recommended for cluster headache treatment. 1
- Ensure adequate oxygen flow rates: Oxygen must be delivered at ≥12 L/min; lower flow rates are ineffective. 2, 4
- Do not use galcanezumab if the patient has chronic cluster headache: This represents a specific contraindication based on evidence. 1, 2
Practical Implementation
Patients should have both acute and prophylactic treatments available simultaneously. 7, 8 Acute treatments (oxygen tank or concentrator at home, injectable sumatriptan) should be readily accessible given the sudden onset of attacks, often occurring at night. 8 Prophylactic therapy should be initiated with transitional bridging (corticosteroids or nerve block) while maintenance therapy takes effect. 7, 4