From the Guidelines
Cluster headache treatment should prioritize high-flow oxygen therapy (12 L/min via a non-rebreather mask) for acute attacks, as recommended by the British Thoracic Society guidelines 1. For acute attacks, this approach is highly effective and safe. Additionally, other treatments such as injectable or nasal sumatriptan can abort attacks within minutes.
- High-flow oxygen therapy is the first-line treatment for acute cluster headache attacks.
- Injectable or nasal sumatriptan can be used as an alternative or in combination with oxygen therapy.
- Preventive treatments, such as verapamil, prednisone, and nerve blocks, can be effective in reducing the frequency and severity of attacks.
- Lifestyle modifications, including avoiding alcohol and maintaining regular sleep patterns, are also important in managing cluster headaches. The most recent guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense 1 suggests noninvasive vagus nerve stimulation for the short-term treatment of episodic cluster headache, but the evidence is weak.
- Noninvasive vagus nerve stimulation may be considered for short-term treatment of episodic cluster headache.
- Other nonpharmacologic therapies, such as physical therapy and aerobic exercise, may be beneficial for managing tension-type and migraine headaches, but their effectiveness for cluster headaches is unclear. It is essential to note that while cluster headaches are extremely painful, they are not life-threatening, and effective treatment options exist. Patients should be reassured and educated on the available treatment options and lifestyle modifications to manage their condition.
From the Research
Cluster Headache Treatment Options
- Acute treatment of cluster headache attacks is strongly recommended with oxygen (100%) at a flow of at least 12 L/min over 15 min and 6 mg subcutaneous sumatriptan 2
- Prophylaxis of cluster headache attacks with verapamil at a daily dose of at least 240 mg is recommended 2
- Corticosteroids, such as prednisone, are efficacious in cluster headache, with a recommended dose of at least 100 mg given orally or up to 500 mg iv per day over 5 days 2
- Alternative treatments include lithium, topiramate, and galcanezumab (only for episodic cluster headache) 2
- Noninvasive vagus nerve stimulation is efficacious in episodic but not chronic cluster headache 2, 3
- Greater occipital nerve block is recommended, but electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile 2
Mechanisms of Action
- The exact underlying mechanism of oxygen therapy in cluster headache is uncertain, but suggested mechanisms include inhibition of the trigeminoautonomic reflex, modulation of neurotransmitters, and cerebral vasoconstriction 4
- High-flow oxygen has been shown to be effective in rendering patients pain-free at 15 minutes, with a significant difference between oxygen and air placebo 5
Emerging Treatment Options
- Calcitonin gene-related peptide antibodies, non-invasive vagus nerve stimulation, sphenopalatine ganglion stimulation, and somatostatin receptor agonists are emerging treatment options for cluster headache 3
- Monoclonal antibodies to the calcitonin gene-related peptide have been shown to be effective for episodic cluster headache 6
- Other investigational drug therapies include ketamine, onabotulinumtoxinA, lysergic acid, and sodium oxybate 6