treatment

Last edited 05/2021 and last reviewed 04/2022

  • the symptoms of cluster headache are characteristic. Early diagnosis is essential for management of this very painful condition (1)
  • the abrupt onset and relatively short lived nature of a cluster headache presents difficulty with management
  • consult expert advice (1)
    • there is no cure for cluster headaches at present. Objective of treatment is to (1):
      • shorten the cluster period in episodic cluster headache
      • reduce the frequency and/or severity of attacks in both episodic and chronic cluster headache
    • acute therapy is aimed at aborting the acute headache, and it must (2):
      • be fast-acting
      • be easily bio-available; parenteral or nasal administration is best
      • provide effective relief

NICE suggest (3)

  • acute treatment
    • offer oxygen and/or a subcutaneous or nasal triptan for the acute treatment of cluster headache
      • when using oxygen for the acute treatment of cluster headache:
        • use 100% oxygen at a flow rate of at least 12 litres per minute for 15 minutes with a non-rebreathing mask and a reservoir bag and
        • arrange provision of home and ambulatory oxygen
    • discuss the need for neuroimaging for people with a first bout of cluster headache with a GP with a special interest in headache or a neurologist
    • do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache (4).
  • prophylactic treatment
    • verapamil
      • is the drug of choice
      • starting dose - 80 mg three times a day and increasing this by 80 mg each fortnight
        • a daily dose of 480 mg is usually needed for adequate control (some patients may need 960 mg as day)
        • perform ECG – before starting treatment, 10 days after the dose change and reviewed before each dose increase
          • special attention should be given to the PR interval (4)
      • if unfamiliar with its use for cluster headache, seek specialist advice before starting verapamil, including advice on electrocardiogram monitoring
    • seek specialist advice for cluster headache that does not respond to verapamil
    • seek specialist advice if treatment for cluster headache is needed during pregnancy

Notes:

  • acute treatment options (1,2):
    • subcutaneous sumatriptan 6mg injection is the treatment of choice (maximum twice daily)
      • alternatives include sumatriptan 20 mg nasal spray or zolmitriptan 5 mg nasal spray, but these have delayed bio-availability
      • sumatriptan and zolmitriptan are contra-indicated in uncontrolled hypertension or the presence of risk factors for coronary heart disease or cerebrovascular disease. Zolmitriptan is contraindicated in patients with Wolff-Parkinson-White syndrome
    • oxygen via non-rebreathing masks; is safe for multiple uses and can be combined with other treatments
      • 100% oxygen at 9-12 L/min for 15 minutes at onset of episode
    • other possible treatments include:
      • intranasal lidocaine
      • ergotamine (Dihydroergotamine) (4)
    • analgesics have no role in management of cluster headache
  • prevention of the attack - two approaches are generally used (1,2)
    • long-term (maintenance) strategy
      • these are taken during the entire cluster period
        • verapamil is first line prophylaxis (80mg tds/qds, but up to 960mg per day may be needed)  
          • to avoid therapeutic delay, short-term prednisolone can be added to verapamil.   
        • lithium
        • methysergide 1-2mg tds may be considered when other treatments fail
    • short-term (transitional) strategy
      • require expert advice
        • corticosteroids – eg. prednisolone 60-100mg per day for 2–5 days, then decreased by 10 mg every 2–3 days   
        • ergotamine tartrate
        • greater occipital nerve injections
    • avoid alcohol and nicotine (1)
  • hypothalamic deep brain stimulation may be useful in intractable chronic cluster headache (2)
  • other guidance suggests a person suspected of a cluster headache requires referral to a neurologist (4)

Reference:

Related pages:

oxygen

sumatriptan

lignocaine

lithium

amitriptyline

methysergide

gammaCore for cluster headaches