What are the treatment options for cluster headaches?

From the Guidelines

High-flow oxygen therapy at 12 L/min via a non-rebreather mask should be offered to treat acute attacks of cluster headache. This recommendation is based on the British Thoracic Society guidelines for home oxygen use in adults 1. The guidelines suggest that SBOT delivering high flow oxygen therapy is effective in treating acute attacks of cluster headache. Key points to consider when implementing this treatment include:

• Ensuring appropriate equipment is provided to deliver high flow rate oxygen at 12 L/min for cluster headache using a non-rebreather mask
• Provision for urgent 4 h installation of home oxygen, if available, rather than a permanent home supply being provided
• Patients will usually have warning of a cluster headache attack, allowing for timely implementation of oxygen therapy The use of high-flow oxygen therapy has been shown to be effective in treating acute cluster headache attacks, and its implementation should be prioritized in clinical practice 1.

From the FDA Drug Label

The efficacy of IMITREX Injection in the acute treatment of cluster headache was demonstrated in 2 randomized, double-blind, placebo-controlled, 2-period crossover trials. Patients age 21 to 65 were enrolled and were instructed to treat a moderate to very severe headache within 10 minutes of onset Headache relief was defined as a reduction in headache severity to mild or no pain. In both trials, the proportion of individuals gaining relief at 10 or 15 minutes was significantly greater among patients receiving 6 mg of IMITREX Injection compared with those who received placebo

The treatment for cluster headache is sumatriptan (SQ) 6 mg.

• Key benefits:
  • Relief from moderate to very severe headache within 10 minutes of onset
  • Significant reduction in headache severity to mild or no pain at 10 or 15 minutes
  • No increase in early recurrence of headache and little effect on the incidence of latter-occurring headaches 2

From the Research

Treatment Options for Cluster Headache

• Acute treatments for cluster headache include:
  • High-flow oxygen therapy, which has been shown to be effective in rendering patients pain-free at 15 minutes 3
  • Subcutaneous sumatriptan, which is a commonly used treatment for acute cluster headache attacks 4
  • Intranasal application of sumatriptan or zolmitriptan, which can provide rapid relief from cluster headache pain 4
• Preventive treatments for cluster headache include:
  • Verapamil, which is a well-established preventive treatment for cluster headache 5, 4
  • Corticosteroids, such as oral prednisolone, which can be used as a bridging therapy until oral prophylactic therapy is effective 5, 4
  • Galcanezumab, which has been shown to be effective in preventing episodic cluster headache attacks 5
• Other treatment options for cluster headache include:
  • Neuromodulation techniques, such as vagus nerve stimulation and occipital nerve stimulation, which can be used for patients who do not respond to medical treatment 5
  • Monoclonal antibodies to the calcitonin gene-related peptide, which have been shown to be effective in preventing episodic cluster headache attacks 4

Efficacy of Oxygen Therapy

• High-flow oxygen therapy has been shown to be effective in treating acute cluster headache attacks, with a significant difference in pain-free rates at 15 minutes compared to placebo 3
• The exact mechanism of oxygen therapy in cluster headache is uncertain, but it is thought to involve inhibition of the trigeminoautonomic reflex, modulation of neurotransmitters, and cerebral vasoconstriction 6
• Oxygen therapy is considered a standard treatment for acute cluster headache, but access to home oxygen therapy can be limited due to insurance coverage issues 6

Efficacy of Triptans

• Triptans, such as zolmitriptan and sumatriptan, have been shown to be effective in treating acute cluster headache attacks, with a significant difference in pain relief rates at 15 and 30 minutes compared to placebo 7
• Non-oral routes of administration, such as subcutaneous and intranasal, are likely to provide better and more rapid responses than oral routes 7
• Triptans may provide a useful treatment option for cluster headache, potentially offering convenience over oxygen therapy and a better safety and tolerability profile than ergotamine 7