What is the recommended treatment for a patient with cluster headaches, considering their potential severity and possible history of cardiovascular disease?

Cluster Headache Treatment

For acute cluster headache attacks, use 100% oxygen at 12 L/min via non-rebreather mask for 15 minutes as first-line therapy, or subcutaneous sumatriptan 6 mg, both of which provide rapid relief within 10-15 minutes. 1, 2, 3

Acute Treatment Algorithm

First-Line Options (Choose Based on Patient Factors)

High-flow oxygen therapy:

• Administer 100% oxygen at minimum 12 L/min via non-rebreather mask for 15 minutes 2, 4
• 78% of patients achieve pain relief compared to 20% with placebo 2
• Critical pitfall: Flow rates below 12 L/min are insufficient—proper equipment is essential 2
• Preferred when cardiovascular disease is present or triptans are contraindicated 5

Subcutaneous sumatriptan 6 mg:

• 49% of patients experience relief within 10 minutes, 74-75% within 15 minutes 2, 3
• For cluster headache specifically: 49% relief at 10 minutes, 74-75% at 15 minutes 3
• Cardiovascular contraindication: Do not use in patients with uncontrolled hypertension, ischemic heart disease, or cerebrovascular disease 3
• The 12 mg dose offers no additional benefit over 6 mg but increases adverse events 3, 6

Alternative acute option:

• Intranasal zolmitriptan 10 mg when subcutaneous administration is not feasible 1, 2

Non-invasive vagus nerve stimulation:

• Effective for episodic cluster headache when medical treatment is contraindicated or side effects are intolerable 1, 5
• Not effective for chronic cluster headache 5

Preventive Treatment Algorithm

For Episodic Cluster Headache

Galcanezumab (First-Line):

• Strongest recommendation with highest quality evidence for episodic cluster headache 1, 2
• Takes 3-6 months to become fully effective 2
• Critical limitation: Not effective for chronic cluster headache—do not prescribe for this population 1, 2

Verapamil (Alternative First-Line):

• Minimum dose 240 mg daily, titrate based on efficacy and tolerability 1, 4
• Commonly used despite insufficient evidence for strong recommendation 1, 2
• Cardiovascular monitoring required: Obtain baseline ECG before initiation; monitor PR interval with ECG when using doses >360 mg daily 1
• Absolute contraindications: Impaired ventricular function, heart failure, or wide-complex tachycardias 1
• May take 2-3 months to become effective 2

For Chronic Cluster Headache

Verapamil:

• Consider despite insufficient evidence, as galcanezumab is specifically not recommended 1
• Same dosing and monitoring requirements as episodic cluster headache 1, 4

Bridge Therapy (While Waiting for Preventives to Take Effect)

Corticosteroids:

• Minimum 100 mg prednisone orally daily or up to 500 mg IV daily for 5 days 4
• Provides rapid effect while waiting for verapamil or galcanezumab to become effective 4, 7

Alternative preventive options:

• Lithium or topiramate when first-line options fail or are contraindicated 4

Cardiovascular Disease Considerations

When cardiovascular disease is present or suspected:

• Prioritize high-flow oxygen therapy over triptans 2, 5
• Avoid subcutaneous sumatriptan in patients with ischemic heart disease, uncontrolled hypertension, or cerebrovascular disease 3
• If verapamil is used, obtain baseline ECG and monitor closely for cardiac conduction abnormalities 1
• Do not use verapamil in patients with heart failure or impaired ventricular function 1

Treatments to Avoid

Do not use:

• Oral ergot alkaloids, opioids, or barbiturates—poor efficacy, potential toxicity, and dependency risks 2
• Implantable sphenopalatine ganglion stimulator—insufficient evidence and weak recommendation against 1, 2

Lifestyle and Trigger Management

Alcohol avoidance:

• 50% of patients report alcohol triggers attacks, particularly red wine in 70% of cases 7
• Advise complete alcohol avoidance during cluster periods 7

Nitrate-containing foods:

• Processed meats and aged cheeses may trigger attacks in some patients 2

Clinical Features to Confirm Diagnosis

Characteristic presentation (distinguish from migraine):

• Strictly unilateral severe headache lasting 15-180 minutes 8
• Ipsilateral cranial autonomic symptoms: lacrimation, nasal congestion, rhinorrhea, ptosis, miosis, eyelid edema 8
• Restlessness during attacks (67.9% of patients) rather than desire to lie still as in migraine 7
• Frequency: 1-8 attacks per day during cluster periods 8
• 23% may have migrainous aura preceding attacks 7