Treatment Options for Cluster Headaches
For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg or high-flow oxygen (100% at ≥12 L/min for 15 minutes), and for prevention of episodic cluster headache, galcanezumab is the first-line prophylactic treatment with the strongest evidence. 1, 2, 3
Acute Treatment (Abortive Therapy)
First-Line Acute Options
Subcutaneous sumatriptan 6 mg is highly effective, achieving headache relief in 70% of patients within 1 hour and 82% within 2 hours, with 65% achieving complete pain freedom by 2 hours. 4 The 2023 VA/DoD guidelines provide a weak recommendation for subcutaneous sumatriptan 6 mg for short-term treatment of cluster headache. 1
- For cluster headache specifically, subcutaneous sumatriptan demonstrates 49% relief at 10 minutes and 74-75% relief at 15 minutes compared to 10-26% with placebo. 4
- The 12 mg dose showed no additional benefit over 6 mg. 4
- Sumatriptan can be used for prolonged periods without loss of efficacy and is effective in both episodic and chronic cluster headache. 5
Intranasal zolmitriptan 10 mg is the alternative triptan option, achieving 62% pain relief at 30 minutes versus 26% with placebo (NNT 2.8). 1, 6
Normobaric oxygen therapy (100% oxygen) at flow rates of at least 12 L/min for 15 minutes is recommended for acute treatment. 1, 2, 7
- Oxygen has no contraindications and can be used in patients with cardiovascular, cerebrovascular, or peripheral vascular disease where triptans are contraindicated. 5
- It can be administered multiple times daily without safety concerns. 5
- The main disadvantage is portability and potential rebound effect. 5
Alternative Acute Treatment
Noninvasive vagus nerve stimulation is suggested for short-term treatment of episodic cluster headache (but not chronic cluster headache). 1, 2, 8
Preventive (Prophylactic) Treatment
First-Line Prevention for Episodic Cluster Headache
Galcanezumab has the strongest evidence among available prophylactic options for episodic cluster headache according to the 2023 VA/DoD guidelines (weak recommendation for). 1, 2, 3, 7
- Critical caveat: Galcanezumab is specifically recommended AGAINST for chronic cluster headache (weak recommendation against). 2, 3
- Do not use if the patient has chronic cluster headache (attacks >1 year without remission). 3
Traditional Preventive Options
Verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is commonly used, though the 2023 VA/DoD guidelines note insufficient evidence to recommend for or against it for either episodic or chronic cluster headache. 1, 2, 7, 9
- Despite insufficient evidence in recent guidelines, verapamil remains a well-documented preventive treatment option. 9
Bridge Therapy
Corticosteroids are recommended as bridge therapy until oral prophylactic treatment becomes effective. 7, 9, 8
- Use at least 100 mg prednisone (or equivalent) orally or up to 500 mg IV per day over 5 days. 7
- Alternative bridge therapy includes pharmacological block of the greater occipital nerves. 9
Alternative Preventive Options
Lithium and topiramate are recommended as alternative preventive treatments. 7
Greater occipital nerve block is recommended for cluster headache treatment. 7
Treatments NOT Recommended
Implantable sphenopalatine ganglion stimulator has a weak recommendation against for cluster headache treatment. 1, 2
Electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile. 7
Common Pitfalls to Avoid
- Do not confuse episodic and chronic cluster headache when prescribing galcanezumab—it is only appropriate for episodic cluster headache. 2, 3
- Avoid oral triptans or intranasal sumatriptan/dihydroergotamine nasal spray as they are scarcely effective compared to subcutaneous administration. 5
- Do not use the 12 mg dose of subcutaneous sumatriptan as it provides no additional benefit over 6 mg. 4
- Ensure oxygen flow rate is at least 12 L/min—lower flow rates are inadequate. 1, 2, 7
- Distinguish between acute treatments (oxygen, sumatriptan) and prophylactic treatments (galcanezumab, verapamil)—they serve different purposes. 3