There are a variety of available cluster headache treatment options that can help provide relief
Cluster headache (CH) is a relatively rare type of headache that belongs to a group of headache disorders called the trigeminal autonomic cephalalgias. While it is one of the most painful headache syndromes, there are cluster headache treatment options available. People can experience cluster headache in a variety of ways, although most experience attacks that recur one to eight times a day. For those with episodic cluster, these painful periods last one or more months and then stop for months or years at a time. However, people who have chronic cluster can go years without any pain-free days. Headache attacks are excruciatingly severe and last between 15 mins and three hours each. During these attacks of pain, people may experience a variety of symptoms, including: red or teary eyes, swollen or drooping eyelids, small pupils, nasal congestion or runny nose, and sweating or swelling of the face–all on the same side as the head pain.
“We call cluster headache a primary headache (like migraine and tension-type headaches) in that it’s not due to other disorders,” says Dr. Stewart Tepper, professor of neurology at the Geisel School of Medicine at Dartmouth. “We don’t know the actual cause of cluster headache, but we do know the anatomy behind it.”
Finding the Right Treatment Options for Cluster Headache
Dr. Tepper has one important piece of advice for patients living with cluster headache: Get to a headache specialist. “Most cluster patients we can treat,” he says. A headache specialist can help you determine the best course of treatment for your symptoms and your lifestyle.
While cluster headache experiences can vary, in most cases it can be successfully treated by individualizing acute and preventive drug treatment. A full treatment plan might include a temporary medication bridge to provide initial relief with steroids, as well as daily preventive medication to help avoid attacks during these weeks-long cycles.
It’s important to note that only sumatriptan and dihydroergotamine injections are FDA-approved for acute treatment of CH, while galcanezumab is approved for the prevention of episodic cluster. The FDA has approved a portable device without significant side effects—the non-invasive vagal nerve stimulator—for the acute headache attacks and preventative treatment of episodic cluster headache attacks. This device is now commercially available with a prescription.
It is important to work with your doctor to arrive at the treatment plan that’s right for you. Read on to see some of the available treatment options that you might find in your plan.
Acute Attack Treatment
Acute treatments for cluster headache include:
Dr. Tepper says one of the most, if not the most, effective treatment options for CH is oxygen. “We recommend patients breathe through a non-rebreathing mask at a high rate of oxygen flow,” he says. “Generally, around 80% of attacks can be terminated by oxygen within 20 minutes.”
Sumatriptan six mg subcutaneous, sumatriptan 20 mg, and zolmitriptan five mg nasal sprays may be effective in the acute treatment of cluster headache, and can help shorten an acute attack. The use of oral triptans to stop an individual cluster attack is not recommended, because cluster attacks reach their peak very quickly and last about an hour, which is sooner than when oral tablets are able to provide relief.
Intramuscular injections may be effective in the relief of acute attacks of CH. An intranasal form, although less effective, may benefit some patients.
Lidocaine nasal drops may be used to treat acute attacks of CH. A nasal dropper may be used and the dose (one mL of 4% lidocaine) can be repeated once after 15 minutes if necessary. This medication must be made up at a special compounding pharmacy.
The options for preventive treatment in CH are determined largely by the length of the attack, as opposed to the designation of episodic versus chronic CH. Preventives may be regarded as short-term or long-term, based on how quickly they act and how long they can be safely used. In general terms, monotherapy is preferred—although some patients, preferably managed by physicians with experience, will require more than one preventive.
Verapamil, a medication used to treat high blood pressure, is a commonly prescribed medication for CH prevention. Verapamil is traditionally started at a low dose, which might be increased to achieve treatment outcomes. EKG’s may be done prior to starting treatment and before the dose is increased, and each patient will need a different dose to achieve remission.
Prednisone may be administered as a short-term bridge for 10-21 days, while waiting for the prevention medications to begin to work. It is often given in a gradually decreasing dosage over several weeks. Prednisone should be used no more than once a year to avoid serious side effects.
Lithium carbonate is mainly used for chronic CH because of its side effects, although it is sometimes employed for the episodic variety.
Studies have shown that topiramate can be an effective option for the preventive treatment of episodic and chronic cluster headache.
CGRP monoclonal antibodies
Galcanezumab received approval from the FDA for preventive treatment of episodic cluster headache.“There’s never been a more hopeful time for cluster patients than right now,” says Dr. Tepper. “The hope is that in three or four years our treatment will be vastly improved.”
The American Migraine Foundation has an extensive collection of information on cluster headache and other disorders that cause severe headache in our resource library. Use our Find a Doctor tool to locate a headache specialist in your area, and discover your support community by joining the Move Against Migraine Facebook Group.
Reviewed for accuracy by the American Migraine Foundation’s subject matter experts, headache specialists and medical advisers with deep knowledge and training in headache medicine. Click here to read about our editorial board members.