Treatment Options for Cluster Headache
For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg or high-flow oxygen (100% at ≥12 L/min for 15 minutes) as first-line therapy, with intranasal zolmitriptan 10 mg as an alternative; for prevention of episodic cluster headache, galcanezumab is the first-line prophylactic agent with the strongest evidence, while verapamil remains an option despite insufficient evidence. 1, 2
Acute Treatment (Abortive Therapy)
First-Line Options
Subcutaneous sumatriptan 6 mg is the most effective acute treatment, with 48% of patients pain-free and 75% achieving no or mild pain within 15 minutes (NNT 3.3 and 2.4 respectively). 3, 4 The 2023 VA/DoD guidelines provide a weak recommendation for subcutaneous sumatriptan 6 mg for short-term treatment of cluster headache. 1
Normobaric oxygen therapy (100% oxygen) should be administered at flow rates of at least 12 L/min for 15 minutes. 1, 2 This is recommended as first-line therapy alongside subcutaneous sumatriptan. 5, 6
Alternative Acute Options
Intranasal zolmitriptan 10 mg is less effective than subcutaneous sumatriptan but still superior to placebo, with 12% pain-free and 28% achieving no or mild pain at 15 minutes (NNT 11 and 4.9 respectively). 1, 4 This is appropriate when subcutaneous administration is not feasible. 5, 7
Important caveat: Oral triptans are not appropriate for cluster headache due to the rapid onset and short duration of attacks. 4 The speed of relief is critical—subcutaneous sumatriptan provides relief in 5-10 minutes, while intranasal formulations take longer. 3, 6
Prophylactic (Preventive) Treatment
Episodic Cluster Headache
Galcanezumab is the first-line prophylactic treatment for episodic cluster headache, representing the strongest evidence among available prophylactic options according to the 2023 VA/DoD guidelines (weak recommendation FOR). 1, 2 This represents a significant advancement in cluster headache prevention. 5, 6
Critical distinction: Galcanezumab is specifically recommended AGAINST for chronic cluster headache (weak recommendation against). 1, 2 Do not use this medication if the patient has chronic cluster headache (attacks occurring for >1 year without remission). 2
Verapamil has been traditionally used as first-line prevention, but the 2023 VA/DoD guidelines state there is insufficient evidence to recommend for or against verapamil for episodic or chronic cluster headache. 1, 2 Despite this, verapamil remains widely used in clinical practice. 5, 6, 8, 7
- Monitoring requirement: Periodic electrocardiograms (EKGs) during dose escalation are essential due to risk of cardiac arrhythmias. 7
- Dosing: Typically requires titration to higher doses for effectiveness. 5, 8
Chronic Cluster Headache
For chronic cluster headache, evidence is more limited. Verapamil and lithium are the most commonly used preventive drugs despite insufficient evidence in guidelines. 5, 8, 7
Lithium requires monitoring of liver and kidney function before and during treatment. 5
Second-line options (when verapamil and lithium fail or are contraindicated) include topiramate, though evidence is limited. 5, 8
Transitional (Bridge) Therapy
Transitional therapy is used to provide rapid relief while waiting for preventive medications to become effective (which can take several weeks). 5, 7
Greater occipital nerve block is the most proven transitional treatment. 5, 7
High-dose oral corticosteroids (prednisone) provide rapid bridging therapy, particularly for patients with high-frequency attacks (>2 per day). 5, 7
Nonpharmacologic Options
Noninvasive vagus nerve stimulation has a weak recommendation FOR the short-term treatment of episodic cluster headache. 1 This provides an additional option when pharmacologic treatments are contraindicated or poorly tolerated. 6
Avoid: The 2023 VA/DoD guidelines recommend AGAINST implantable sphenopalatine ganglion stimulators for cluster headache treatment (weak recommendation against). 1
Critical Clinical Considerations
- Timing matters: Patients should treat attacks within 10 minutes of onset for optimal efficacy. 3
- Route of administration: Non-oral routes (subcutaneous, intranasal, inhalation) are essential due to rapid attack onset. 6, 4, 7
- Combination approach: Use acute treatment for attacks while establishing prophylaxis; transitional therapy bridges the gap. 5, 7
- Monitoring for galcanezumab: Watch for injection site reactions and hypersensitivity. 2
- Distinguish episodic from chronic: This distinction is critical for selecting galcanezumab (only for episodic) versus other preventive options. 1, 2