Cluster Headache Treatment
For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg or 100% oxygen at 12 L/min for 15 minutes as first-line therapy; for prevention of episodic cluster headache, galcanezumab is the first-line prophylactic treatment with the strongest evidence. 1, 2
Acute Treatment of Cluster Headache Attacks
First-Line Acute Therapies
- Subcutaneous sumatriptan 6 mg provides relief in 70% of patients within 10 minutes and 74-75% within 15 minutes 3, 4
- 100% oxygen inhalation at flow rates of at least 12 L/min for 15 minutes is equally effective and has no contraindications, making it ideal for patients with cardiovascular disease where triptans are contraindicated 1, 4
- Intranasal zolmitriptan 10 mg is an alternative when subcutaneous administration is not feasible 1, 4
Important Acute Treatment Considerations
- Sumatriptan nasal spray and dihydroergotamine nasal spray are considerably less effective than subcutaneous sumatriptan and should not be first-line choices 5
- Oxygen therapy advantages include no side effects, no contraindications, and ability to use multiple times daily, though it may cause rebound headaches 5
- Do not use oral sumatriptan for cluster headache—a controlled trial showed preemptive oral sumatriptan 100 mg three times daily for 7 days did not reduce attack frequency or severity 6
- Noninvasive vagus nerve stimulation is suggested for short-term treatment of episodic cluster headache only 1
Prophylactic Treatment
Episodic Cluster Headache Prevention
- Galcanezumab is first-line prophylaxis for episodic cluster headache with the strongest evidence among available options 1, 2
- Verapamil at doses of at least 240 mg daily (maximum dose depends on efficacy and tolerability) is commonly used, though recent guidelines note insufficient evidence to definitively recommend for or against it 1, 4
- Obtain baseline ECG before initiating verapamil and monitor PR interval when using doses >360 mg daily, as cluster headache often requires doses double those used in cardiology 1
- Do not use verapamil in patients with impaired ventricular function, heart failure, or wide-complex tachycardias 1
Chronic Cluster Headache Prevention
- Do not use galcanezumab for chronic cluster headache—guidelines specifically recommend against it 1, 2
- There is insufficient evidence to recommend for or against verapamil for chronic cluster headache prevention 1, 2
- Lithium and topiramate are alternative prophylactic options 4, 7
Bridging Therapy
- Corticosteroids provide rapid prophylactic effect while waiting for maintenance therapy to become effective 4
- Use at least 100 mg prednisone (or equivalent) orally or up to 500 mg IV per day over 5 days 4
- Greater occipital nerve block is recommended as an alternative bridging strategy 4
Critical Pitfalls to Avoid
- Never use opioids or butalbital for cluster headache treatment—these are explicitly not recommended 8
- Do not confuse episodic and chronic cluster headache when prescribing galcanezumab—it is only effective for episodic cluster headache 1, 2
- Do not use implantable sphenopalatine ganglion stimulator—guidelines recommend against this intervention 1
- Electrical stimulation of the greater occipital nerve is not recommended due to unfavorable side effect profile 4
- Monitor for galcanezumab injection site reactions and hypersensitivity 2
Treatment Algorithm
- Confirm diagnosis: Unilateral periorbital pain lasting 15-180 minutes with autonomic symptoms (lacrimation, rhinorrhea, ptosis) occurring in clusters 2
- Acute attack management: Prescribe both subcutaneous sumatriptan 6 mg autoinjector AND home oxygen setup (100% at 12 L/min) 1, 3, 4
- Initiate prophylaxis for episodic cluster headache: Start galcanezumab as first-line 1, 2
- Consider bridging therapy: Use prednisone 100 mg daily or greater occipital nerve block while prophylaxis takes effect 4
- If episodic cluster headache becomes chronic (attacks >1 year without remission): Discontinue galcanezumab and consider verapamil, lithium, or topiramate 1, 2, 7