What are the differences in treatment for cluster headaches, tension headaches, and migraines?

Treatment Differences: Cluster vs Tension vs Migraine Headaches

The treatment approaches for these three headache types are fundamentally distinct: cluster headaches require high-flow oxygen (12 L/min) or subcutaneous sumatriptan for acute attacks with galcanezumab for prevention; migraines respond to triptans, gepants, or aspirin-acetaminophen-caffeine combinations acutely with multiple preventive options including topiramate, valproate, and CGRP inhibitors; tension-type headaches are managed with simple analgesics like ibuprofen (400 mg) or acetaminophen (1000 mg) acutely and amitriptyline for chronic prevention. 1, 2

Cluster Headache Treatment

Acute Management

• First-line acute treatment is 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes, achieving pain relief in 78% of patients compared to 20% with placebo 2
• Subcutaneous sumatriptan 6 mg provides rapid relief, with 49% experiencing relief within 10 minutes and 74-75% within 15 minutes 2
• Intranasal zolmitriptan 10 mg serves as an alternative to subcutaneous sumatriptan 2
• Critical pitfall: oxygen flow rates below 12 L/min are insufficient—proper equipment and adequate flow rates are essential for effectiveness 2

Preventive Management

• Galcanezumab is the first-line prophylactic treatment for episodic cluster headache based on the strongest available evidence 2
• Verapamil is commonly used but lacks strong evidence for formal recommendation 2
• Important caveat: galcanezumab is NOT effective for chronic cluster headache and should not be prescribed for this population 2
• Preventive medications may require 2-3 months to become effective 2

Additional Options

• Noninvasive vagus nerve stimulation is suggested for episodic cluster headache, particularly when medical treatment is contraindicated or side effects are intolerable 2, 3
• Avoid oral ergot alkaloids, opioids, or barbiturates due to poor efficacy, potential toxicity, and dependency risks 2

Migraine Treatment

Acute Management

• Primary care clinicians should consider triptans, aspirin-acetaminophen-caffeine combinations, and CGRP inhibitors (gepants) as first-line options for acute migraine treatment 1
• Newer ditans block CGRP release by binding to 5-HT1F receptors, offering an alternative mechanism to triptans 1

Preventive Management for Episodic Migraine

• Effective preventive medications include angiotensin-receptor blockers, lisinopril, topiramate, valproate, eptinezumab, and atogepant 1
• Propranolol (80-240 mg/day) and timolol (20-30 mg/day) have consistent evidence for efficacy 1
• Amitriptyline (30-150 mg/day) is the most studied antidepressant with consistent support for prevention 1
• Divalproex sodium and sodium valproate have good evidence, though adverse events include weight gain, hair loss, tremor, and teratogenic potential 1
• Gabapentin is NOT recommended for prevention of episodic migraine 1

Chronic Migraine Prevention

• AbobotulinumtoxinA can be used for prevention of chronic migraine but NOT episodic migraine 1

Non-Pharmacologic Approaches

• Aerobic exercise or physical therapy can be used in migraine management 1

Tension-Type Headache Treatment

Acute Management

• Ibuprofen 400 mg and acetaminophen 1000 mg are first-line treatments for acute tension-type headache 1
• NSAIDs are the mainstay of acute treatment 4

Preventive Management

• Amitriptyline is recommended for prevention of chronic tension-type headache 1
• Tricyclic antidepressants have the most evidence as prophylactic therapy 4

Non-Pharmacologic Approaches

• Aerobic exercise or physical therapy can be used in tension-type headache management 1

Key Distinguishing Clinical Features

Cluster Headache Characteristics

• Strictly unilateral, severe pain lasting 15-180 minutes with prominent ipsilateral autonomic symptoms including lacrimation, nasal congestion, and ptosis 3
• Often triggered by alcohol and strong smells 3

Tension-Type Headache Characteristics

• Bilateral with pressing, tightening, or non-pulsatile character, mild to moderate severity 5
• Not aggravated by routine physical activity 5
• Lacks nausea/vomiting, though may have anorexia; typically doesn't have both photophobia and phonophobia 5

Migraine Characteristics

• Often unilateral, throbbing character, moderate to severe intensity 5
• Worsens with activity 5
• Associated with nausea/vomiting and photophobia/phonophobia 5

Critical Treatment Pitfalls

• For cluster headaches, never use inadequate oxygen flow rates—12 L/min minimum is essential 2
• Do not prescribe galcanezumab for chronic cluster headache—it only works for episodic cluster 2
• Do not use abobotulinumtoxinA for episodic migraine—it is only effective for chronic migraine 1
• Do not use gabapentin for episodic migraine prevention—evidence does not support this 1
• Always rule out secondary headache causes before confirming primary headache diagnosis, particularly with red flags such as sudden onset, fever, focal neurological symptoms, or onset after age 50 3, 5