What are the treatment options for cluster headaches?

Cluster Headache Treatment

Acute Treatment: First-Line Options

For acute cluster headache attacks, start with high-flow oxygen at 12 L/min via non-rebreather mask for 15 minutes, which provides pain relief in 78% of patients within 15 minutes. 1

High-Flow Oxygen Therapy

• Administer 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes at attack onset 1, 2
• This achieves pain relief (reduction to mild or no pain) in 78% of patients compared to 20% with placebo 1
• Critical pitfall: Flow rates below 12 L/min may be insufficient—proper equipment and adequate flow rates are essential for efficacy 1
• While some evidence suggests 7 L/min may work, the guideline-recommended standard is 12 L/min to ensure consistent effectiveness 1, 2

Subcutaneous Sumatriptan

• Use 6 mg subcutaneous sumatriptan as an equally effective first-line option 1, 2
• Provides rapid relief with 49% of patients pain-free within 10 minutes and 74-75% within 15 minutes 1
• For cluster headache specifically, 74-75% achieve pain relief at 15 minutes post-injection 3
• The 12 mg dose offers no additional benefit over 6 mg 3

Intranasal Zolmitriptan

• Use intranasal zolmitriptan 10 mg as an alternative to subcutaneous sumatriptan 1, 2
• This provides a non-injectable option for patients who cannot or prefer not to use subcutaneous administration 2

Noninvasive Vagus Nerve Stimulation

• Consider noninvasive vagus nerve stimulation for short-term treatment of episodic cluster headache 1, 2
• This is particularly useful when medications are contraindicated or poorly tolerated 2

Preventive Treatment: Episodic Cluster Headache

For episodic cluster headache prevention, galcanezumab is the first-line prophylactic treatment with the strongest evidence among available options. 1, 2

First-Line Prevention

• Galcanezumab is recommended as first-line prophylaxis for episodic cluster headache based on the highest quality evidence 1, 2
• Important caveat: Galcanezumab is effective for episodic but NOT chronic cluster headache 1, 2

Alternative Preventive Options

• Verapamil (at least 240 mg daily) is commonly used for prevention, though recent guidelines note insufficient evidence for a strong recommendation 1, 2
• Despite limited evidence quality, verapamil remains a practical option when galcanezumab is unavailable or contraindicated 2

Preventive Treatment: Chronic Cluster Headache

For chronic cluster headache, do NOT use galcanezumab—there is a weak recommendation against its use in this population. 2

Treatment Approach for Chronic Form

• Galcanezumab should not be used for chronic cluster headache prevention 2
• Verapamil may be considered, though evidence is insufficient to make a definitive recommendation for or against it 2
• For treatment-refractory chronic cluster headache, invasive neuromodulation options like occipital nerve stimulation may be considered, though implantable sphenopalatine ganglion stimulators are not recommended 2

Bridge Therapy

• Use corticosteroids (oral prednisolone or suboccipital injections) as bridge therapy until oral prophylactic treatment becomes effective 2
• This prevents attacks during the lag time before preventive medications reach therapeutic effect 2

Treatment Algorithm

1. For acute attacks: Start with high-flow oxygen (12 L/min via non-rebreather mask for 15 minutes) OR subcutaneous sumatriptan 6 mg 1, 2
2. For episodic cluster headache prevention: Initiate galcanezumab as first-line prophylaxis 1, 2
3. For chronic cluster headache prevention: Consider verapamil (galcanezumab is not effective) 2
4. Bridge therapy: Use corticosteroids while waiting for preventive medications to take effect 2