Maximum Treatment Dosages for Cluster Headache
For acute cluster headache treatment, use subcutaneous sumatriptan 6 mg with a maximum of 12 mg per 24 hours, or 100% oxygen at 12 L/min for 15 minutes with no maximum daily limit. 1, 2
Acute Treatment Maximum Dosages
First-Line Acute Therapies
Subcutaneous Sumatriptan:
- Maximum single dose: 6 mg 2, 3
- Maximum daily dose: 12 mg per 24 hours (can repeat once after 1 hour if needed) 4, 5
- This is the most effective acute treatment with 70-82% efficacy within 15 minutes 1
100% Oxygen:
- Flow rate: At least 12 L/min for 15 minutes 6, 2
- No maximum daily limit - can be used for each attack 2
- Has no cardiovascular contraindications, making it safer than triptans for patients with cardiac disease 1
Second-Line Acute Therapies
Intranasal Sumatriptan:
- Maximum single dose: 20 mg 1
- Can repeat if headache recurs (occurs in approximately 40% of responders within 24 hours) 1
- Less effective than subcutaneous formulation but useful when injections are not tolerated 1
Intranasal Zolmitriptan:
Dihydroergotamine (DHE):
- Maximum IM/SC dose: 3 mg per day 4
- Maximum IV dose: 2 mg per day 4
- Maximum weekly dose: 6 mg 4
- Intranasal: Maximum 2 mg per day (four 0.5-mg sprays) 4
Preventive Treatment Maximum Dosages
First-Line Prophylaxis
Verapamil (for episodic or chronic cluster headache):
- Minimum effective dose: 240 mg daily 6, 2
- Typical clinical doses: 480-720 mg daily 3
- Maximum dose: Depends on efficacy and tolerability 2
- Critical monitoring requirement: Obtain baseline ECG and monitor PR interval when using doses >360 mg daily 6, 3
- Contraindicated in patients with impaired ventricular function, heart failure, AV block greater than first degree, or SA node dysfunction without pacemaker 6
Galcanezumab (for episodic cluster headache ONLY):
- Recommended as first-line prophylactic treatment with strongest evidence for episodic cluster headache 6, 8
- Specifically NOT recommended for chronic cluster headache (weak recommendation against) 6, 8
Alternative Prophylactic Options
Lithium:
- Recommended as alternative treatment 2
- Requires liver and kidney function monitoring before and during treatment 7
Topiramate:
- Recommended as alternative treatment 2
- Second choice if verapamil and lithium are ineffective or contraindicated 7
Corticosteroids (Transitional/Bridging Therapy):
- Minimum effective dose: 100 mg prednisone (or equivalent) orally 2
- Maximum: Up to 500 mg IV per day over 5 days 2
- Used for high-frequency attacks (>2 per day) until prophylactic therapy becomes effective 5, 7
Critical Contraindications and Drug Interactions
Triptans (including sumatriptan and zolmitriptan):
- Contraindicated with ischemic heart disease, vasospastic coronary disease, uncontrolled hypertension, or significant cardiovascular disease 1
- Cannot be used concurrently with ergotamine derivatives due to additive vasoconstrictive effects 1
- Cannot combine different triptans - must allow adequate washout period 1
- Contraindicated with MAOIs 4
Verapamil:
- Moderate CYP3A4 inhibitor and P-glycoprotein inhibitor requiring careful monitoring of drug interactions 6
- Contraindicated with dofetilide 6
- Requires careful monitoring with dabigatran, edoxaban, rivaroxaban, flecainide, simvastatin, and digoxin 6
- Avoid grapefruit juice 6
Common Pitfalls to Avoid
- Do not confuse acute and prophylactic treatments - oxygen and sumatriptan treat individual attacks, not prevention 1, 8
- Do not use galcanezumab if patient has chronic cluster headache (attacks >1 year without remission) 6, 8
- Do not exceed maximum daily triptan doses to avoid medication overuse and cardiovascular complications 4
- Do not escalate verapamil doses without ECG monitoring - doses used in cluster headache may be double those used in cardiology 6, 3
- Do not combine ergotamine derivatives with triptans within 24 hours due to vasoconstrictive risks 4, 1