What is the first line treatment for a patient presenting with cluster migraines?

First-Line Treatment for Cluster Headache

Subcutaneous sumatriptan 6 mg is the first-line abortive treatment for cluster headache attacks, providing the fastest and most complete relief with 75% of patients achieving pain relief within 15 minutes. 1

Primary Treatment Options

Subcutaneous Sumatriptan 6 mg (Preferred First-Line)

• Delivers the highest efficacy among all cluster headache treatments, with 49% of patients pain-free at 10 minutes and 74-75% achieving relief by 15 minutes 1, 2
• Onset of relief begins as early as 10 minutes, with 70-82% experiencing pain relief within 15 minutes 3, 4
• The 6 mg dose is optimal; the 12 mg dose showed no statistically significant improvement over 6 mg 3
• Can be self-administered using an autoinjector for rapid home treatment 3
• Relieves both the excruciating headache and accompanying autonomic symptoms (ptosis, miosis, lacrimation, nasal congestion) 4

High-Flow Oxygen Therapy (Co-First-Line Option)

• Normobaric oxygen at 7-12 liters per minute for 15 minutes is equally recommended as first-line therapy 1, 4
• Advantages include no contraindications, can be used in patients with cardiovascular disease (unlike triptans), and can be administered multiple times daily 5
• Free from side effects and particularly valuable for patients with cardiac, cerebral, or peripheral vascular disease where sumatriptan is contraindicated 5
• Disadvantages include portability issues and potential rebound effect 5

Second-Line Treatment Options

Intranasal Zolmitriptan 10 mg

• Recommended when subcutaneous administration is not feasible or refused by the patient 1
• Less effective than subcutaneous sumatriptan, with only 12% pain-free at 15 minutes and 28% achieving relief (compared to 48% and 75% with subcutaneous sumatriptan) 2
• NNT of 11 for pain-free response and 4.9 for pain relief at 15 minutes 2

Intranasal Zolmitriptan 5 mg

• Lower efficacy than the 10 mg dose and significantly inferior to subcutaneous sumatriptan for rapid 15-minute responses 2

Treatment Algorithm

1. First attempt: Subcutaneous sumatriptan 6 mg at attack onset (within 10 minutes of headache start) 1, 3
2. If subcutaneous route refused or unavailable: High-flow oxygen 7-12 L/min for 15 minutes 1, 4
3. If both above options fail or contraindicated: Intranasal zolmitriptan 10 mg 1
4. Maximum dosing: Do not exceed two 6 mg doses of sumatriptan in 24 hours 3

Critical Contraindications to Sumatriptan

• Ischemic heart disease or previous myocardial infarction 6
• Uncontrolled hypertension 6
• Basilar or hemiplegic migraine 1
• Cerebral or peripheral vascular disease 5
• Prinzmetal (variant) angina 6
• In these patients, oxygen therapy becomes the sole first-line option 5

Common Pitfalls to Avoid

• Do not use oral triptans for cluster headache - oral routes are not appropriate due to the rapid onset and short duration of cluster attacks requiring immediate relief 2
• Do not administer sumatriptan with ergotamines or methysergide - concurrent use of vasoconstrictive substances is contraindicated 6
• Do not use intranasal sumatriptan - it has scarcely effective results for cluster headache compared to subcutaneous administration 5
• Do not delay treatment - cluster headache attacks require treatment within 10 minutes of onset for optimal efficacy 3
• Avoid noninvasive vagus nerve stimulation as first-line - while suggested for episodic cluster headache, it has only weak evidence and should not replace proven therapies like subcutaneous sumatriptan or oxygen 1

Preventive Therapy Consideration

• If attacks occur frequently (more than twice weekly), initiate preventive therapy with verapamil as first-line prophylaxis while continuing acute treatment 4
• Transitional treatment with greater occipital nerve block may be considered while titrating preventive medications 4