What are the treatment options for managing cluster headaches?

Management of Cluster Headache

Acute Treatment

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 therapy. 1

High-Flow Oxygen Therapy

• Administer 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes at attack onset 1, 2
• 78% of patients achieve pain relief at 15 minutes compared to 20% with placebo 2, 3
• Flow rates below 12 L/min are insufficient—proper equipment and adequate flow rates are critical 2
• No contraindications, no adverse effects, and can be used multiple times daily 4
• Particularly valuable for patients with cardiovascular disease where triptans are contraindicated 4
• Home oxygen concentrators (using two units connected together) provide effective alternative to oxygen tanks 5

Subcutaneous Sumatriptan

• Dose: 6 mg subcutaneously 1, 2, 6
• 49% of patients achieve pain relief within 10 minutes, 74-75% within 15 minutes 2, 6
• 70% achieve headache relief (reduction to mild or no pain) within 1 hour 6
• Rapid onset of relief begins as early as 10 minutes following injection 6
• Can be self-administered using an autoinjector 6

Alternative Acute Treatment

• Intranasal zolmitriptan 10 mg is an alternative when subcutaneous sumatriptan is not feasible 1, 2

Non-Invasive Neuromodulation

• Noninvasive vagus nerve stimulation can be used for short-term treatment of episodic cluster headache 1, 2

Preventive Treatment

Episodic Cluster Headache

Galcanezumab is the first-line preventive treatment for episodic cluster headache based on the strongest available evidence. 1, 2

• Galcanezumab has the strongest evidence among available preventive options for episodic cluster headache 2
• Critical caveat: Galcanezumab is NOT effective for chronic cluster headache and should be avoided in this population 1, 2
• Preventive medications may require 2-3 months to become effective 2

Verapamil Considerations

• Verapamil is commonly used in clinical practice for prevention 1, 2
• However, insufficient evidence exists to make a strong recommendation for or against verapamil for either episodic or chronic cluster headache 1, 2

Bridge Therapy

• Corticosteroids (oral or suboccipital injections) serve as bridge treatments while waiting for preventive medications to take effect 7

Treatment Algorithm

For Acute Attacks:

1. First-line: High-flow oxygen (12 L/min, 100% via non-rebreather mask for 15 minutes) OR subcutaneous sumatriptan 6 mg 1, 2
2. Alternative: Intranasal zolmitriptan 10 mg if first-line options unavailable 1, 2
3. Adjunct: Consider noninvasive vagus nerve stimulation for episodic cluster headache 1, 2

For Prevention:

1. Episodic cluster headache: Galcanezumab as first-line preventive 1, 2
2. Chronic cluster headache: Do NOT use galcanezumab 1, 2
3. Bridge therapy: Consider corticosteroids while initiating preventive treatment 7

Critical Pitfalls to Avoid

• Never use oxygen flow rates below 12 L/min—inadequate flow is a common reason for treatment failure 2
• Never prescribe galcanezumab for chronic cluster headache—it is ineffective in this population 1, 2
• Avoid oral ergot alkaloids, opioids, or barbiturates—these have poor efficacy, potential toxicity, and risk of dependency 2
• Ensure proper non-rebreather mask is used with oxygen therapy, not a simple face mask 2, 3
• Recognize that preventive therapy requires patience—allow 2-3 months for medication effect 2
• Be aware that nitrate-containing foods (processed meats, aged cheeses) may trigger attacks 2

Invasive Options for Refractory Cases

• Occipital nerve stimulation may be considered for treatment-refractory chronic cluster headache 7
• Sphenopalatine ganglion stimulator is NOT recommended 1