Cluster Headache Treatment
For acute cluster headache attacks, initiate high-flow oxygen at 100% and 12 L/min via non-rebreather mask for 15 minutes, or subcutaneous sumatriptan 6 mg; for prevention of episodic cluster headache, galcanezumab is the first-line prophylactic agent with the strongest evidence. 1, 2
Acute Treatment Algorithm
First-Line Options (Choose Based on Availability and Patient Preference)
High-flow oxygen therapy is the primary acute treatment: administer 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes, which provides pain relief in 78% of patients compared to 20% with placebo 1, 3
Subcutaneous sumatriptan 6 mg provides rapid relief with 49% of patients pain-free within 10 minutes and 74-75% within 15 minutes 1
Intranasal zolmitriptan 10 mg serves as an alternative to subcutaneous sumatriptan for patients who cannot tolerate injections 1
Critical Pitfall to Avoid
Oxygen flow rates below 12 L/min are insufficient—proper equipment with adequate flow capacity is essential for efficacy 1, 4
Home oxygen concentrators can be effective when two units are connected together to achieve adequate flow rates 5
Preventive Treatment Algorithm
For Episodic Cluster Headache
Galcanezumab is the first-line prophylactic treatment based on the strongest evidence among available options according to VA/DoD and American Academy of Neurology guidelines 1, 2
Monitor for injection site reactions and hypersensitivity with galcanezumab 2
Verapamil at daily doses of at least 240 mg is commonly used for prevention, though guideline evidence is weaker than for galcanezumab; maximum dose depends on efficacy and tolerability 1, 4
For Chronic Cluster Headache
Do NOT use galcanezumab for chronic cluster headache (attacks >1 year without remission)—guidelines specifically recommend against it 2
Verapamil remains an option, though evidence is insufficient for strong recommendations 1, 2
Alternative preventive options include lithium and topiramate 4
Bridge Therapy (Until Prophylaxis Takes Effect)
Oral corticosteroids: Use at least 100 mg prednisone (or equivalent) daily, or up to 500 mg IV per day over 5 days 4
Greater occipital nerve block with local anesthetic and corticosteroid provides rapid transitional relief 4, 6
Non-Pharmacologic Options
- Noninvasive vagus nerve stimulation is effective for short-term treatment of episodic cluster headache but not chronic cluster headache 1, 4, 6
Key Clinical Distinctions
Episodic vs. Chronic Cluster Headache
- Episodic cluster headache: Attack periods lasting weeks to months with remission periods
- Chronic cluster headache: Attacks occurring for >1 year without remission or with remission periods <3 months
- This distinction is critical because galcanezumab is effective only for episodic cluster headache 2, 4
Common Pitfalls
Do not confuse acute and prophylactic treatments—oxygen and triptans are for individual attacks, not prevention 2
Ensure proper oxygen delivery equipment; standard nasal cannulas cannot deliver the required 12 L/min flow rate 1
Oral triptans are inadequate for cluster headache due to slow onset; only subcutaneous sumatriptan or intranasal zolmitriptan provide sufficiently rapid relief 1, 6