What is the treatment for cluster headaches?

Treatment of Cluster Headaches

For acute cluster headache attacks, use high-flow oxygen (100% at 12 L/min via non-rebreather mask for 15 minutes) or subcutaneous sumatriptan 6 mg as first-line therapy, and for prevention of episodic cluster headache, galcanezumab is the strongest evidence-based option. 1

Acute Treatment Algorithm

First-Line Options

• High-flow oxygen therapy is the primary acute treatment: deliver 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes, which provides relief in 78% of patients compared to 20% with placebo 1

  • Critical pitfall: Flow rates below 12 L/min are insufficient and will fail to abort attacks 1
  • Ensure proper equipment is available, as standard nasal cannulas cannot deliver adequate flow rates 1

• Subcutaneous sumatriptan 6 mg provides the fastest pharmacologic relief: 49% of patients achieve pain relief within 10 minutes and 74-75% within 15 minutes 1

  • This is more effective than oxygen for speed of onset 1

Alternative Acute Options

• Intranasal zolmitriptan 10 mg serves as an alternative when subcutaneous sumatriptan is contraindicated or not tolerated 1
• Noninvasive vagus nerve stimulation can be used for episodic cluster headache, particularly when medical treatments are contraindicated or side effects are intolerable 1

Medications to Avoid

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

Preventive Treatment Algorithm

First-Line Prevention

• Galcanezumab is recommended as first-line prophylaxis for episodic cluster headache based on the strongest available evidence 1
  • Important limitation: Galcanezumab is NOT effective for chronic cluster headache and should not be prescribed for this population 1
  • Expect 3-6 months for monoclonal antibodies to reach full effectiveness 1

Second-Line Prevention

• Verapamil at a daily dose of at least 240 mg (titrate based on efficacy and tolerability) is commonly used, though evidence is less robust than for galcanezumab 1, 2

  • Mandatory monitoring: Obtain ECG before initiating verapamil and during dose escalation due to cardiac side effects 3
  • Maximum dose depends on individual efficacy and tolerability 2

• Lithium is an alternative preventive option 3, 2

  • Mandatory monitoring: Evaluate liver and kidney function before and during treatment 3

Third-Line Prevention

• Topiramate should be considered if verapamil and lithium are ineffective, contraindicated, or discontinued due to side effects 3, 2

Additional Options with Lower Evidence

• Melatonin, gabapentin, and divalproex sodium may be considered when standard options fail 3, 4
• Important note: Preventive oral medications may take 2-3 months to become effective 1

Transitional (Bridge) Therapy

Use transitional therapy to provide relief while waiting for preventive medications to take effect:

• Greater occipital nerve block is the most proven transitional treatment 3, 2
• Corticosteroids: Use at least 100 mg prednisone (or equivalent) orally, or up to 500 mg IV per day over 5 days 2
  • High-dose prednisone provides rapid but temporary relief while titrating long-term preventive therapy 3

Treatment-Refractory Chronic Cluster Headache

• Consider neuromodulatory options when all pharmacologic treatments fail 3
• Do not use implantable sphenopalatine ganglion stimulator due to insufficient evidence 1
• Noninvasive vagus nerve stimulation is efficacious for episodic but not chronic cluster headache 2

Key Clinical Considerations

• Timing expectations: Set realistic expectations that preventive medications require weeks to months for full effect (2-3 months for oral medications, 3-6 months for monoclonal antibodies) 1
• Trigger avoidance: Counsel patients that nitrate-containing foods (processed meats, aged cheeses) may trigger attacks 1
• Episodic vs. chronic distinction: Treatment selection differs significantly—galcanezumab works only for episodic cluster headache 1