How to Treat Cluster Headache
Cluster headache treatment is divided into three main categories: acute, transitional therapy, and preventive therapy. As acute treatment, the inhalation of high flow oxygen by non-rebreather mask for fifteen minutes during a cluster attack is the first-line treatment. When oxygen is not available, fast-acting triptans should be considered. Injectable sumatriptan provides the fastest relief, making it the triptan of choice for cluster headache. However, intranasal triptans are an alternative. Oral triptans can be considered for individuals who have prolonged cluster attacks, but their relatively slow onset of action makes them less desirable compared to injectable and nasal spray formulations. Other options for treating cluster attacks include non-invasive vagus nerve stimulation in episodic cluster headache, intranasal lidocaine, ergotamine, and dihydroergotamine.
Transitional therapy can be used to provide temporary relief while waiting for the benefits of preventive therapy. A one-to-two-week course of steroids is effective for reducing cluster attack frequency while they are being taken. Injection of corticosteroids with an analgesic, such as bupivacaine, over the expected location of the greater occipital nerve can also provide temporary relief from cluster headaches and is associated with substantially less systemic corticosteroid exposure compared to oral administration.
Preventive therapy reduces the frequency of cluster attacks. For individuals with episodic cluster headache, preventive therapy is used during the cluster period and typically discontinued after the cluster period ends. Verapamil, a calcium channel blocker, is the first-line treatment for cluster headache prevention. Available data and clinical impression suggest that verapamil is effective for most patients with cluster headache. Electrocardiogram monitoring is necessary to screen for cardiac conduction delays during verapamil therapy. Although lithium might be similarly effective as verapamil, it does not provide benefits as quickly and is associated with more side effects than verapamil, making it second or third-line therapy. Newer options for episodic cluster headache prevention include galcanezumab, a calcitonin gene-related peptide monoclonal antibody that is effective for episodic cluster prevention, and non-invasive vagus nerve stimulation which has evidence for episodic cluster headache prevention. Other treatment options, although with less published evidence, include topiramate and melatonin, as well as valproic acid, baclofen, and methysergide. Invasive neuromodulation is reserved for the most refractory patients.
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