What are the treatment options for cluster migraines?

Treatment of Cluster Headache

For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg or high-flow oxygen (100% at 12 L/min via non-rebreather mask for 15 minutes), as these provide the fastest and most effective relief, with oxygen achieving pain freedom in 78% of patients at 15 minutes and sumatriptan in 70% at 1 hour. 1, 2, 3

Acute Treatment Algorithm

First-Line Acute Options (Choose Based on Availability and Patient Preference)

Subcutaneous Sumatriptan 6 mg:

• Delivers pain relief in 70% of patients within 1 hour and 82% within 2 hours 2
• Onset begins as early as 10 minutes, with 49% achieving relief by 10 minutes and 74-75% by 15 minutes in cluster headache trials 1, 2
• Maximum of two 6 mg doses in 24 hours 2
• Contraindications: Ischemic heart disease, previous myocardial infarction, uncontrolled hypertension, or significant cardiovascular disease 2

High-Flow Oxygen (100% at 12 L/min):

• Administer via non-rebreather face mask for 15 minutes at attack onset 1, 3
• Achieves pain freedom in 78% of patients at 15 minutes versus 20% with placebo 3
• No significant adverse events reported 3
• Home oxygen concentrators (using two units connected together) provide 31.7% substantial pain reduction at 15 minutes and 57.1% at 30 minutes 4
• Preferred by 61.3% of patients over oral medications 4

Intranasal Zolmitriptan 10 mg:

• Alternative when subcutaneous route is not feasible 1, 5
• Less rapid onset than subcutaneous sumatriptan but effective 5

Second-Line Acute Option

Non-invasive Vagus Nerve Stimulation:

• Recommended for episodic cluster headache when first-line treatments are contraindicated or poorly tolerated 1, 6

Important Acute Treatment Considerations

• Avoid implantable sphenopalatine ganglion stimulators - guidelines suggest against their use 1
• Intranasal sumatriptan is also effective but less studied than the 10 mg zolmitriptan formulation 5
• Treatment should be initiated within 10 minutes of attack onset for optimal efficacy 1

Preventive Treatment Algorithm

Bridge Therapy (Use While Waiting for Preventive to Take Effect)

Oral Corticosteroids (Prednisolone):

• Provides rapid temporary relief while initiating long-term preventive therapy 5, 6

Greater Occipital Nerve Block:

• Alternative bridge therapy option 5, 6

Long-Term Preventive Therapy

For Episodic Cluster Headache:

• Galcanezumab - weak recommendation for prevention of episodic cluster headache 1, 6
• Verapamil - best documented preventive, though current guidelines note insufficient evidence to make a formal recommendation 1, 5, 6
• Alternative options: Lithium, gabapentin, topiramate, divalproex sodium, or melatonin (possibly effective) 5

For Chronic Cluster Headache:

• Avoid galcanezumab - guidelines suggest against its use for chronic cluster headache 1
• Verapamil remains the most commonly used despite insufficient formal evidence 1, 5, 6
• Occipital nerve stimulation - option for treatment-refractory chronic cluster headache 6

Critical Pitfalls to Avoid

• Do not use oral triptans - cluster headache attacks peak too rapidly for oral medications to be effective; only subcutaneous or intranasal routes work 2, 5
• Do not use standard oxygen flow rates - must use high-flow (12 L/min) with 100% oxygen via non-rebreather mask, not nasal cannula 1, 3
• Do not confuse episodic and chronic cluster headache - galcanezumab is only recommended for episodic, not chronic forms 1
• Do not delay bridge therapy - initiate corticosteroids or nerve blocks immediately when starting preventive therapy, as verapamil and other preventives take weeks to become effective 5, 6

Mechanism of Action Insights

Most effective treatments act on the trigeminovascular system, autonomic nervous system, or hypothalamus 6. Oxygen therapy's mechanism relates to effects on the trigeminovascular system and neuroinflammation 7. This explains why rapid-acting, non-oral routes are essential for acute treatment success.