What is the appropriate acute and preventive treatment for a patient with typical episodic or chronic cluster headache?

Cluster Headache Treatment

Acute Treatment

For acute cluster headache attacks, use subcutaneous sumatriptan 6 mg or 100% oxygen at 12 L/min for 15 minutes as first-line therapy, with subcutaneous sumatriptan being the most effective pharmacologic option (74-75% relief within 15 minutes). 1

First-Line Acute Options

• Subcutaneous sumatriptan 6 mg is the gold standard acute treatment, achieving headache relief in 74-75% of patients within 15 minutes 1, 2
• 100% oxygen at 12 L/min for 15 minutes is equally first-line and has no cardiovascular contraindications, making it safer for patients with cardiac risk factors 1, 3

Second-Line Acute Options (when first-line not tolerated or unavailable)

• Intranasal zolmitriptan 10 mg achieves no or mild pain in 28% of patients by 15 minutes 1, 3
• Intranasal sumatriptan 20 mg is less effective than subcutaneous formulation, with approximately 40% of responders experiencing recurrence within 24 hours (a second dose can be administered if headache recurs) 3, 1

Critical Contraindications for Triptans

• Screen for ischemic heart disease, Prinzmetal's angina, uncontrolled hypertension, Wolff-Parkinson-White syndrome, and history of stroke or TIA before prescribing triptans 1
• Do not use triptans concurrently with ergotamine derivatives due to additive vasoconstrictive effects 3
• Limit triptan use to ≤10 days per month to prevent medication overuse headache 1

Preventive Treatment

For episodic cluster headache prevention, galcanezumab is the first-line prophylactic treatment with the strongest available evidence, while verapamil remains a traditional option despite insufficient guideline-level evidence. 4, 1

First-Line Preventive Therapy

• Galcanezumab has the strongest evidence for episodic cluster headache prevention according to 2023 VA/DoD guidelines (weak recommendation FOR) 4, 1
• Monitor for injection site reactions and hypersensitivity with galcanezumab 4

Important Preventive Treatment Distinctions

• Do NOT use galcanezumab for chronic cluster headache (attacks >1 year without remission)—it has a weak recommendation AGAINST in this population 4
• Verapamil is traditionally considered the mainstay of prophylactic therapy, though 2023 VA/DoD guidelines state there is insufficient evidence to recommend for or against it for either episodic or chronic cluster headache 4, 2

Bridge Therapy

• Corticosteroids (oral or suboccipital injections) provide short-term fast-acting prevention while establishing maintenance prophylaxis 2, 5
• This transitional approach prevents attacks during the initiation period of slower-acting preventive medications 2

Treatment Algorithm

For Acute Attacks:

1. Start with subcutaneous sumatriptan 6 mg OR 100% oxygen at 12 L/min for 15 minutes (choose oxygen if cardiovascular contraindications exist) 1
2. If subcutaneous sumatriptan is not tolerated or practical, use intranasal zolmitriptan 10 mg 1
3. If both above fail or are unavailable, use intranasal sumatriptan 20 mg 3, 1

For Prevention:

1. For episodic cluster headache: Start galcanezumab as first-line prophylaxis 4, 1
2. For chronic cluster headache: Do NOT use galcanezumab; consider verapamil, lithium, or other options 4
3. Bridge therapy: Use corticosteroids during prophylaxis initiation 2
4. Ensure acute treatments (oxygen, triptans) are available for breakthrough attacks 4

Common Pitfalls to Avoid

• Do not confuse acute and prophylactic treatments—oxygen and sumatriptan treat individual attacks, not prevention 4
• Do not use galcanezumab if the patient has chronic cluster headache (continuous attacks >1 year without remission) 4
• Do not combine triptans with ergotamine derivatives due to additive vasoconstrictive effects 3
• Do not use triptans concurrently with other triptans—allow adequate washout period 3
• Do not exceed 10 days per month of triptan use to prevent medication overuse headache 1

Special Considerations

• Cluster headache requires rapid-acting, non-oral routes for acute treatment due to the quick peak of pain 2
• Attacks frequently occur at night and have distinctive circadian/circannual periodicity in episodic forms 2, 6
• For medically refractory chronic cluster headache, neuromodulation options (occipital nerve stimulation, vagus nerve stimulation, deep brain stimulation) may be considered 2, 7