Treatment of Cluster Headache and Tension-Type Headache
Cluster Headache: Acute Treatment
For acute cluster headache attacks, administer high-flow oxygen at 12 L/min via a non-rebreather mask as first-line therapy. 1
Oxygen Therapy Protocol
- Deliver 100% oxygen at 12 L/min (not lower flow rates) via a non-rebreather mask for 15-30 minutes at attack onset 1, 2
- Higher flow rates up to 15 L/min may provide superior efficacy compared to lower rates 3, 2, 4
- Patients typically experience warning signs before attacks, allowing time for oxygen administration 1
- Oxygen provides pain relief in approximately 70% of cluster headache patients, with episodic cluster headache responding better than chronic cluster headache 5
Alternative Acute Medications When Oxygen Fails or Is Unavailable
- Subcutaneous sumatriptan 6 mg is the most effective pharmacologic option, providing relief within 15 minutes 1
- Intranasal zolmitriptan 10 mg serves as an alternative when subcutaneous administration is not feasible 1
Critical Implementation Details
- Appropriate equipment must deliver the required high flow rate of 12 L/min—standard nasal cannulae are inadequate 1
- Non-rebreather masks are essential; simple face masks or nasal cannulae will not achieve therapeutic oxygen delivery 1, 2
- Provision should be made for urgent 4-hour installation of home oxygen rather than permanent supply, since attacks are episodic 1
Cluster Headache: Preventive Treatment
First-Line Preventive Option
- Galcanezumab is recommended for prevention of episodic cluster headache 1
- Galcanezumab should not be used for chronic cluster headache, as evidence shows it is ineffective in this population 1
Alternative Preventive Consideration
- Verapamil has insufficient evidence to make a firm recommendation for either episodic or chronic cluster headache prevention, though it is commonly used in clinical practice 1
Tension-Type Headache: Acute Treatment
For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line therapy. 1
Dosing Specifics
- Ibuprofen 400 mg orally at headache onset provides effective relief for tension-type headache 1
- Acetaminophen 1000 mg (not lower doses) is the alternative when NSAIDs are contraindicated 1
- Lower doses of acetaminophen (500-650 mg) lack statistically significant benefit and should not be used 6
Medication Frequency Limits
- Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache 1, 6
- Using acute medications ≥15 days per month creates a cycle of daily headaches that perpetuates the problem 6
Tension-Type Headache: Preventive Treatment
When to Initiate Prevention
- Consider preventive therapy when tension-type headache becomes chronic (≥15 headache days per month) 1
- Prevention is also indicated when acute medication use exceeds twice weekly 1
Preventive Medication
- Amitriptyline is the recommended preventive agent for chronic tension-type headache 1
- Typical effective doses range from 30-150 mg daily, with higher doses often needed for adequate response 1, 7
- Allow 2-3 months at target dose before assessing efficacy 7
Treatment to Avoid
- Botulinum toxin injections should not be used for tension-type headache prevention, as evidence does not support efficacy in this population 1
Common Pitfalls to Avoid
- Do not prescribe oxygen at flow rates below 12 L/min for cluster headache—lower rates (e.g., 2-6 L/min) are ineffective and represent the most common reason for treatment failure 5, 2
- Do not use standard nasal cannulae for cluster headache oxygen therapy; only non-rebreather masks deliver adequate flow 1, 2
- Do not allow patients to use acute headache medications more than 2 days per week, as this creates medication-overuse headache regardless of headache type 1, 6
- Do not prescribe acetaminophen at doses below 1000 mg for tension-type headache, as lower doses lack proven efficacy 6
- Do not use botulinum toxin for tension-type headache—it is only FDA-approved and effective for chronic migraine, not tension-type headache 1