What are the treatment options for cluster headaches?

Cluster Headache Treatment

Acute Treatment

For acute cluster headache attacks, initiate high-flow oxygen therapy at 100% oxygen delivered at 12 L/min via non-rebreather mask for 15 minutes, or subcutaneous sumatriptan 6 mg, both of which are first-line treatments with the strongest evidence. 1

First-Line Acute Options

• High-flow oxygen (100% at 12 L/min for 15 minutes) provides pain relief in 78% of patients compared to 20% with placebo, making it highly effective for acute attacks 1, 2

  • Flow rates below 12 L/min are insufficient—proper equipment and adequate flow rates are essential to achieve therapeutic benefit 1
  • Home oxygen concentrators connecting two units can deliver adequate oxygen flow and provide superior pain relief compared to oral medications 3

• Subcutaneous sumatriptan 6 mg delivers rapid relief with 49% of patients experiencing pain relief within 10 minutes and 74-75% within 15 minutes 1

  • At 1 hour, 70% achieve headache relief (reduction to mild or no pain) 4
  • For cluster headache specifically, 49% achieve relief at 10 minutes and 74-75% at 15 minutes 4

• Intranasal zolmitriptan 10 mg serves as an alternative to subcutaneous sumatriptan when injection is not feasible 1, 5

Non-Pharmacologic Acute Option

• Noninvasive vagus nerve stimulation is suggested for short-term treatment of episodic cluster headache, particularly when medical treatment is contraindicated or side effects are intolerable 1, 5, 6

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Preventive Treatment

For episodic cluster headache prevention, galcanezumab is recommended as first-line prophylactic treatment based on the strongest available evidence. 1, 5

First-Line Preventive Options

• Galcanezumab is the first-line prophylactic treatment for episodic cluster headache with the strongest evidence among available options 1, 5

  • Critical caveat: Galcanezumab is NOT effective for chronic cluster headache and should not be prescribed for this population 1, 5
  • Monoclonal antibodies may take 3-6 months to become fully effective 1

• Verapamil (at least 240 mg daily, with maximum dose depending on efficacy and tolerability) is commonly used for prevention, though recent guidelines note insufficient evidence to make a strong recommendation 1, 5, 6

  • Cardiac monitoring is essential: Obtain baseline ECG before initiating therapy and monitor PR interval with ECG when using doses >360 mg daily, as cluster headache doses may be double those used in cardiology 5
  • Contraindications: Do not give verapamil to patients with impaired ventricular function, heart failure, or wide-complex tachycardias 5
  • Oral preventive medications may take 2-3 months to become effective 1

Bridge Therapy

• Corticosteroids (oral prednisone at least 100 mg or equivalent, or up to 500 mg IV per day over 5 days) are efficacious for bridging until preventive therapy becomes effective 6, 7

Alternative Preventive Options

• Lithium and topiramate are recommended as alternative preventive treatments when first-line options fail or are contraindicated 6, 7

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Critical Medications to Avoid

• Do not use oral ergot alkaloids, opioids, or barbiturates for cluster headache treatment due to poor efficacy, potential toxicity, and risks of dependency 1

• Implantable sphenopalatine ganglion stimulator is not recommended due to insufficient evidence 1, 5

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Treatment Algorithm

For Acute Attacks:

1. Start with high-flow oxygen (12 L/min via non-rebreather mask for 15 minutes) OR subcutaneous sumatriptan 6 mg 1, 5
2. If oxygen or sumatriptan are contraindicated or unavailable, use intranasal zolmitriptan 10 mg 1, 5
3. Consider noninvasive vagus nerve stimulation if medical treatments are contraindicated or poorly tolerated 1, 5

For Prevention:

1. Episodic cluster headache: Start galcanezumab as first-line prophylaxis 1, 5
2. Chronic cluster headache: Use verapamil (at least 240 mg daily with appropriate cardiac monitoring) as galcanezumab is ineffective 1, 5
3. Initiate bridge therapy with corticosteroids while waiting for preventive medications to take effect 6
4. Consider lithium or topiramate as second-line preventive options 6, 7

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Common Pitfalls

• Insufficient oxygen flow: Oxygen flow rates below 12 L/min are inadequate for treating cluster headaches—ensure proper equipment and flow rates 1

• Wrong galcanezumab population: Galcanezumab is only effective for episodic cluster headache, not chronic cluster headache 1, 5

• Inadequate verapamil monitoring: Failure to obtain baseline ECG and monitor PR intervals at higher doses can lead to cardiac complications 5

• Delayed preventive effect: Patients and clinicians must understand that preventive medications take 2-3 months (oral medications) or 3-6 months (monoclonal antibodies) to become fully effective 1

• Trigger awareness: Nitrate-containing foods (processed meats, aged cheeses) may trigger attacks in some patients 1