Treatment of Cluster Headaches
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 as first-line therapy; for prevention of episodic cluster headache, galcanezumab is the first-line prophylactic treatment. 1
Acute Treatment Algorithm
First-Line Options (Choose One)
High-flow oxygen therapy is the preferred initial treatment for most patients:
- Administer 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes 1
- 78% of patients achieve pain relief compared to 20% with placebo 1, 2
- Critical pitfall: Flow rates below 12 L/min are insufficient—proper equipment and adequate flow rates are essential for efficacy 1
- Safe with no important adverse events 2
Subcutaneous sumatriptan 6 mg provides the most rapid relief:
- 49% of patients experience pain relief within 10 minutes and 74-75% within 15 minutes 1
- Fastest-acting pharmacologic option available 1
Alternative Acute Options
Intranasal zolmitriptan 10 mg serves as an alternative when subcutaneous sumatriptan is contraindicated or not tolerated 1
Noninvasive vagus nerve stimulation can be considered for short-term treatment of episodic cluster headache 1
Medications to Avoid
Never use oral ergot alkaloids, opioids, or barbiturates for cluster headache treatment due to poor efficacy, potential toxicity, and dependency risks 1
Preventive Treatment Algorithm
First-Line Prophylaxis
Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache based on the strongest available evidence 1
- Important limitation: Galcanezumab is NOT effective for chronic cluster headache and should not be prescribed for this population 1
- Monoclonal antibodies may take 3-6 months to become fully effective 1
Second-Line Prophylaxis
Verapamil is commonly used for prevention, though evidence is insufficient for a strong recommendation 1
- Remains a mainstay of prophylactic therapy in clinical practice 3, 4, 5
- Oral preventive medications may take 2-3 months to become effective 1
Bridging Therapy
While waiting for preventive medications to take effect, consider:
Treatment Selection Based on Cluster Headache Type
For episodic cluster headache:
For chronic cluster headache:
- Acute: High-flow oxygen or subcutaneous sumatriptan 1
- Preventive: Verapamil (galcanezumab is ineffective) 1
- Consider neuromodulation for treatment-refractory cases 3
Practical Implementation Considerations
Timing of acute treatment is critical—initiate therapy at the earliest sign of attack onset for maximum efficacy 1, 3
Trigger avoidance: Counsel patients to avoid nitrate-containing foods such as processed meats and aged cheeses, which may trigger attacks 1
Equipment requirements: Ensure patients have access to proper non-rebreather masks and oxygen delivery systems capable of 12-15 L/min flow rates 1, 6