What is the drug of choice for treating cluster headaches and what foods should be avoided to manage them?

Cluster Headache: Drug of Choice and Management

Acute Treatment - First-Line Therapy

For acute cluster headache attacks, use high-flow oxygen (100% at 12 L/min via non-rebreather mask for 15 minutes) or subcutaneous sumatriptan 6 mg as first-line treatments. 1

High-Flow Oxygen Therapy

• Administer 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes at the onset of an attack 1, 2
• Provides pain relief in 78% of patients compared to 20% with placebo 1
• Flow rates below 12 L/min are insufficient and represent a common pitfall 1
• Home oxygen concentrators (using two units connected together) can effectively substitute for oxygen tanks and provide better relief than oral medications 3
• No adverse events reported with oxygen therapy 3, 2

Subcutaneous Sumatriptan

• Administer 6 mg subcutaneously at attack onset 1, 4
• Provides rapid relief with 49% of patients pain-free within 10 minutes and 74-75% within 15 minutes 1
• Most effective injectable option for acute attacks 5

Alternative Acute Treatments

• Intranasal zolmitriptan 10 mg serves as an alternative when subcutaneous sumatriptan is contraindicated 1, 4
• Intranasal sumatriptan is also effective but less studied than zolmitriptan 4

Preventive Treatment

For episodic cluster headache prevention, galcanezumab is the first-line option with the strongest evidence, though verapamil remains commonly used. 1

First-Line Preventive

• Galcanezumab has the strongest evidence for episodic cluster headache prophylaxis 1
• Important caveat: Galcanezumab is effective for episodic but NOT chronic cluster headache 1

Traditional Preventive Options

• Verapamil at a minimum daily dose of 240 mg (maximum dose depends on efficacy and tolerability) 5
• Verapamil is commonly used despite insufficient evidence for strong recommendations 1
• Lithium serves as an alternative preventive agent 4, 5
• Topiramate, gabapentin, divalproex sodium, and melatonin are possibly effective 4

Bridging Therapy

Use oral corticosteroids or occipital nerve blocks as bridging therapy until preventive medications become effective. 4, 5

• Oral prednisolone or methylprednisone at least 100 mg daily (or up to 500 mg IV per day over 5 days, then taper) 5
• Pharmacological block of the major occipital nerves provides an alternative bridging approach 4
• Bridging therapy is critical because preventive medications require weeks to months for efficacy 4

Non-Pharmacologic Options

• Noninvasive vagus nerve stimulation for short-term treatment of episodic cluster headache 1
• Occipital nerve stimulation for treatment-refractory chronic cluster headache 6

Foods and Triggers to Avoid

While the provided evidence does not specifically address dietary triggers for cluster headaches, general medical knowledge indicates:

• Alcohol is the most important trigger to avoid during cluster periods, as it can precipitate attacks within minutes to hours
• Nitrate-containing foods (processed meats, aged cheeses) may trigger attacks in some patients
• Histamine-rich foods should be considered for avoidance during active cluster periods

Critical Pitfalls to Avoid

• Do not use oral ergot alkaloids, opioids, or barbiturates - these are poorly effective, potentially toxic, and carry risks of dependency 7
• Do not use oxygen flow rates below 12 L/min - this is insufficient for cluster headache treatment 1
• Do not prescribe galcanezumab for chronic cluster headache as it lacks efficacy in this population 1
• Do not expect immediate results from preventive therapy - efficacy requires 2-3 months for oral medications and 3-6 months for monoclonal antibodies 7