What are the guidelines for managing cluster headaches?

Management of Cluster Headache

Acute Treatment

For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg or high-flow oxygen (100% at 12 L/min) as first-line therapy, both achieving relief in approximately 70% of patients within 10-15 minutes. 1, 2

First-Line Acute Therapies

• Subcutaneous sumatriptan 6 mg is the most effective acute treatment, with 70% of patients achieving relief within 10 minutes and 74% within 15 minutes 1, 2, 3

  • Pain freedom occurs in 48-49% of patients at 1 hour 3
  • The 12 mg dose offers no additional benefit over 6 mg but increases adverse events 4
  • Screen for cardiovascular risk factors (hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history of CAD) before prescribing, as triptans cause vasoconstriction 2

• 100% oxygen inhalation at 12 L/min provides equal efficacy to sumatriptan, with 70% of patients achieving relief within 10 minutes 2

  • This is the preferred option for patients with cardiovascular contraindications to triptans 1

Alternative Acute Therapy

• Intranasal zolmitriptan 10 mg is an effective alternative when subcutaneous administration is not feasible 1, 5

Non-Invasive Neuromodulation

• Non-invasive vagus nerve stimulation is recommended specifically for episodic cluster headache when medications are contraindicated or poorly tolerated 1, 6

Preventive Treatment

Verapamil is the prophylactic drug of choice, starting at 360 mg/day, with ECG monitoring for PR interval prolongation at higher doses. 2

First-Line Preventive Therapy

• Verapamil 360 mg/day is the most established preventive treatment 2, 5
  • Monitor ECG for PR interval prolongation, especially at higher doses 2
  • Titrate slowly to effective dose while monitoring for adverse effects 5

Newer Preventive Options

• Galcanezumab (CGRP monoclonal antibody) is effective for episodic cluster headache only, not for chronic cluster headache 2
  • This represents a significant advancement for patients with episodic patterns 6

Additional Preventive Agents

• Lithium is particularly useful for chronic cluster headache and can be added to verapamil for refractory cases 2, 5
• Topiramate and divalproex sodium may be considered as add-on therapy for chronic cluster headache 2, 5

Bridging Therapy

Use oral corticosteroids or greater occipital nerve blockade as bridging therapy while waiting for verapamil to take effect, as preventive medications require 2-3 weeks to become effective. 2, 5

Bridging Options

• Oral prednisolone provides rapid temporary relief during the initiation of preventive therapy 5
• Greater occipital nerve blockade offers an alternative bridging approach, particularly for patients who cannot tolerate corticosteroids 2, 5

Treatment Algorithm by Cluster Headache Type

Episodic Cluster Headache

1. Acute attacks: Subcutaneous sumatriptan 6 mg OR 100% oxygen at 12 L/min 1, 2
2. Bridging: Oral corticosteroids or occipital nerve block 2, 5
3. Prevention: Verapamil 360 mg/day OR galcanezumab 2
4. Alternative prevention: Lithium, topiramate, or divalproex sodium 2, 5

Chronic Cluster Headache

1. Acute attacks: Same as episodic (sumatriptan or oxygen) 1, 2
2. Prevention: Verapamil as first-line 2, 5
3. Refractory cases: Add lithium, topiramate, or divalproex sodium 2
4. Note: Galcanezumab is NOT effective for chronic cluster headache 2

Invasive Interventions for Refractory Cases

• Implantable sphenopalatine ganglion stimulator is recommended against for cluster headache treatment 1
• Occipital nerve stimulation may be considered for drug-refractory chronic cluster headache when all medical treatments have failed 6, 7

Critical Diagnostic Considerations

Distinguish cluster headache from migraine by the shorter attack duration (15-180 minutes vs 4-72 hours), presence of ipsilateral autonomic symptoms (lacrimation, rhinorrhea, conjunctival injection), and restless behavior during attacks (pacing) rather than lying still. 2

Red Flags Requiring Neuroimaging

• Focal neurological deficits 2
• Atypical headache pattern 2
• Progressive worsening 2
• New neurological symptoms or abnormal examination 2
• MRI brain is the preferred imaging modality 2

Comparative Effectiveness

• There is insufficient evidence to recommend one specific medication over another for cluster headache prevention 1
• There is insufficient evidence to recommend specific combination therapies 1
• However, clinical practice strongly favors verapamil as first-line based on the most robust evidence base 2, 5

Common Pitfalls to Avoid

• Do not use oral triptans for cluster headache—the rapid onset requires subcutaneous or intranasal routes 6, 5
• Do not prescribe sumatriptan without cardiovascular screening, as the severe pain may mask cardiac symptoms 2
• Do not expect immediate effect from verapamil—bridging therapy is essential during the 2-3 week onset period 2
• Do not use galcanezumab for chronic cluster headache—it is only effective for episodic patterns 2