Horton (Cluster) Headache: Symptoms and Management
Clinical Presentation
Cluster headache presents with severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes, occurring from every other day up to 8 times daily, accompanied by ipsilateral autonomic symptoms and restlessness. 1, 2
Diagnostic Criteria
- Pain characteristics: Severe to excruciating unilateral pain in orbital/supraorbital/temporal region 1, 2
- Attack frequency: 1 attack every other day up to 8 attacks per day 1
- Attack duration: 15-180 minutes if untreated 1, 2
- Required autonomic features (at least one ipsilateral to pain): 1, 2
- Lacrimation (most common)
- Conjunctival injection
- Nasal congestion or rhinorrhea
- Forehead/facial sweating
- Ptosis
- Miosis
- Eyelid edema
- Behavioral feature: Sense of agitation or restlessness during attacks 2
- Minimum diagnostic requirement: 5 attacks meeting above criteria 1
Common Triggers
- Alcohol consumption during active cluster periods 2, 3
- Nitroglycerin and nitrate-containing foods 2
- Strong odors (tobacco, nail polish, petroleum) 4, 2
Acute (Abortive) Treatment
First-Line Acute Therapies
For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg OR intranasal zolmitriptan 10 mg as first-line pharmacotherapy, combined with high-flow oxygen therapy. 1, 4
Oxygen Therapy (Preferred First-Line)
- Administration: 100% oxygen via non-rebreather mask at ≥12 L/min for 15 minutes 1, 5
- Efficacy: Pain relief achieved in 49% at 10 minutes and 75% at 15 minutes 6
- Advantages: No adverse events, preferred by 61.3% of patients over oral medications 7
- Home oxygen concentrators: Two concentrators connected in parallel provide equivalent efficacy to oxygen tanks (31.7% substantial pain reduction at 15 minutes) 7
Triptan Therapy
- Subcutaneous sumatriptan 6 mg: 1, 6
- Relief in 49% at 10 minutes, 74-75% at 15 minutes
- Onset as early as 10 minutes
- Superior to all other doses studied
- Intranasal zolmitriptan 10 mg: Alternative first-line option 1
- Oral zolmitriptan 5 mg: Less effective (12.9% substantial relief at 15 minutes vs 31.7% with oxygen) 7
Preventive (Prophylactic) Treatment
First-Line Prophylaxis
For episodic cluster headache prevention, galcanezumab is the first-line prophylactic agent with the strongest evidence base. 1, 4
Galcanezumab (CGRP Monoclonal Antibody)
- Indication: Episodic cluster headache prevention (weak for recommendation) 1, 4
- Critical caveat: Recommended AGAINST for chronic cluster headache 1, 4
- Monitoring: Watch for injection site reactions and hypersensitivity 4
Verapamil
- Evidence status: Insufficient evidence to recommend for or against for episodic or chronic cluster headache 1, 4
- Historical use: Previously considered first-line but lacks robust evidence in current guidelines 8, 3
Other Prophylactic Options (Insufficient Evidence)
- Lithium: Historically used, limited current evidence 8, 3
- Topiramate, gabapentin, divalproex sodium, melatonin: Possibly effective but insufficient evidence 8, 2
Transitional (Bridging) Therapy
Use oral corticosteroids or greater occipital nerve blocks as bridging therapy while establishing prophylaxis. 8, 2
- Oral prednisolone: Can induce remission of frequent, severe attacks 8, 3
- Suboccipital steroid injections: Alternative bridging option 2
- Purpose: Provide rapid relief until oral prophylactic medications become effective 8
Nonpharmacologic Interventions
Noninvasive Vagus Nerve Stimulation
- Recommendation: Weak for recommendation for acute treatment of episodic cluster headache 1
- Use case: Consider when pharmacotherapy is contraindicated or ineffective 1
Interventions NOT Recommended
- Implantable sphenopalatine ganglion stimulator: Weak against recommendation 1
- Insufficient evidence: Greater occipital nerve blocks, supraorbital nerve blocks, various neuromodulation devices for cluster headache 1
Critical Management Pitfalls
Common Errors to Avoid
- Do NOT use galcanezumab for chronic cluster headache (defined as attacks >1 year without remission) 1, 4
- Do NOT confuse acute and preventive treatments: Oxygen and triptans are for attacks, not prevention 4
- Do NOT recommend alcohol consumption during active cluster periods: This is a potent trigger 2, 3
- Do NOT use inadequate oxygen flow rates: Must be ≥12 L/min via non-rebreather mask, not nasal cannula 5
- Do NOT delay oxygen therapy: Should be initiated within 10 minutes of attack onset 9
Patient Education Essentials
- Maintain headache diaries to track attack patterns and triggers 3
- Keep oxygen and sumatriptan readily available for acute attacks 4
- Understand the distinction between episodic (remission periods) and chronic (no remission >1 year) cluster headache, as this affects treatment selection 4
- Avoid known triggers, particularly alcohol during active cluster periods 3