What are the treatment options for a patient experiencing cluster headaches?

Cluster Headache Management

Acute Treatment

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. 1, 2

High-Flow Oxygen Therapy

• Administer 100% oxygen at a flow rate of at least 12 L/min via non-rebreather mask for 15 minutes 1, 2, 3
• Provides pain relief in 78% of patients compared to 20% with placebo 2
• Critical pitfall: Flow rates below 12 L/min are insufficient—proper equipment and adequate flow rates are essential for efficacy 2
• Advantages include no contraindications (safe in cardiovascular, renal, hepatic disease), no side effects, and can be used multiple times daily 4
• Disadvantages include limited portability and potential rebound effects 4

Subcutaneous Sumatriptan

• Administer 6 mg subcutaneously at attack onset 1, 2, 5
• Provides rapid relief with 49% of patients experiencing pain relief within 10 minutes, 74-75% within 15 minutes, and 70% achieving headache relief within 1 hour 2, 5
• For cluster headache specifically, 74-75% of patients achieve pain relief (reduction to mild or no pain) at 15 minutes post-injection 5
• The 12 mg dose offers no additional benefit over 6 mg 5

Alternative Acute Treatments

• Intranasal zolmitriptan 10 mg is an alternative to subcutaneous sumatriptan 1, 2
• Noninvasive vagus nerve stimulation is suggested for episodic cluster headache, particularly when medical treatment is contraindicated or side effects are intolerable 1, 2

Medications to Avoid

• Do not use oral ergot alkaloids, opioids, or barbiturates due to poor efficacy, potential toxicity, and dependency risks 2

Preventive Treatment

Episodic Cluster Headache

Galcanezumab is the first-line prophylactic treatment for episodic cluster headache based on the strongest available evidence. 2, 6

• Galcanezumab receives a weak recommendation from VA/DoD guidelines specifically for episodic cluster headache 1, 6
• Important caveat: Galcanezumab is NOT effective for chronic cluster headache and should not be prescribed for this population 1, 2, 6
• Preventive monoclonal antibodies may take 3-6 months to become effective 2

Verapamil as Alternative Prevention

• Verapamil at a daily dose of at least 240 mg is commonly used for prevention (maximum dose depends on efficacy and tolerability) 6, 7
• Recent VA/DoD guidelines note insufficient evidence to recommend for or against verapamil for episodic or chronic cluster headache 1, 6
• Cardiac monitoring is essential: Obtain baseline ECG before initiating therapy and monitor PR interval with ECG when using doses >360 mg daily 6
• Contraindications: Do not give verapamil to patients with impaired ventricular function, heart failure, or wide-complex tachycardias 6

Chronic Cluster Headache Prevention

• Galcanezumab is specifically NOT recommended for chronic cluster headache 1, 6
• There is insufficient evidence to recommend for or against verapamil for chronic cluster headache prevention 6

Transitional (Bridging) Therapy

Use corticosteroids or greater occipital nerve block as bridging therapy while waiting for oral prophylactic medications to become effective. 7

Corticosteroids

• Administer at least 100 mg prednisone (or equivalent) orally, or up to 500 mg IV per day over 5 days 7
• Provides rapid effect while maintenance prophylaxis takes 2-3 months to become effective 2

Greater Occipital Nerve Block

• Recommended as an alternative bridging therapy option 7
• Suggested for short-term treatment of cluster headache 1

Treatment Algorithm

1. For acute attacks: Start with high-flow oxygen (12 L/min for 15 minutes) or subcutaneous sumatriptan 6 mg 1, 2

2. For episodic cluster headache prevention: Initiate galcanezumab as first-line prophylaxis 2, 6

3. For bridging therapy: Use corticosteroids (≥100 mg prednisone daily) or occipital nerve block while waiting for prophylactic medications to take effect 2, 7

4. If verapamil is chosen: Start at ≥240 mg daily with baseline ECG and cardiac monitoring for doses >360 mg daily 6, 7

Interventional Procedures Not Recommended

• Implantable sphenopalatine ganglion stimulator is not recommended due to insufficient evidence 2, 6
• Electrical stimulation of the greater occipital nerve is not recommended due to unfavorable side effect profile 7

Lifestyle Considerations

• Avoid nitrate-containing foods (processed meats, aged cheeses) as they may trigger attacks in some patients 2