Treatment

• 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. The 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 (1):
    • be fast-acting
    • be easily bio-available; parenteral or nasal administration is best
    • provide effective relief
• Acute treatment
  • acute treatment is focused on parenteral triptans and inhaled high-flow oxygen (2,3)
    • high-flow oxygen given at a rate of 12-15 L/minute for at least 15 minutes (or until the attack is terminated) using a non-rebreathing face mask has been shown to be effective in the acute treatment of cluster attacks, decreasing both the intensity and duration of attacks. It is safe, can be used multiple times a day, and is not contraindicated in patients with hypertension or vascular disease. (2,3)
    • 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
• subcutaneous sumatriptan has been shown to be effective and is the preferred triptan for treating acute attacks. Intranasal zolmitriptan and sumatriptan are effective and well tolerated, with nearly 50% of patients given either drug reporting freedom from pain. (2,3)
• oral formulations are generally less effective than subcutaneous and intranasal formulations because symptoms begin with little or no warning and peak rapidly, but there is some evidence for effectiveness of oral zolmitriptan. (2,3) Remember that cardiovascular risk factors (e.g., coronary artery disease, cerebrovascular disease, or uncontrolled hypertension) can preclude the use of triptans.
• Note - intranasal lidocaine can bring about rapid relief of cluster attacks in at least one third of patients. Application should be as close as possible to the sphenopalatine fossa. (4)
• Prophylactic treatment
  • verapamil is considered the first-line preventative therapy for both episodic and chronic cluster headache (2,3)
    • starting dose is 80 mg three times a day and increasing this by 80 mg every 3-4 days, with an ECG before starting treatment and before each dose increase. Special attention should be given to the PR interval (3)
      • a daily dose of 480 mg is usually needed for adequate control (some patients may need 960 mg as day)
    • 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 or if treatment for cluster headache is needed during pregnancy.

Note - galcanezumab, a humanised monoclonal antibody against calcitonin gene-related peptide, was reported to reduce the weekly frequency of episodic cluster headache attacks measured in the 3-week period after the initial injection, compared with placebo. (1)​ Efficacy in preventing chronic cluster headache was not demonstrated in a randomised, placebo-controlled study, but a retrospective real-world study suggested benefit for some patients. ​(5) Galcanezumab is approved in the US for the treatment of episodic cluster headache, and is recommended in European guidelines as an off-label treatment option for patients with intractable episodic cluster headache (it is only approved for the treatment of migraine in Europe).

There has been much research into electrical stimulation. Sites of stimulation include the sphenopalatine ganglion, occipital, and vagus nerve. Deep brain stimulation of the hypothalamus has been very successful and has proven helpful in treating drug-resistant patients.(6) Vagus nerve stimulation can be an option with a nonimplanted device. (7)

Reference:

1. Schindler EAD, Burish MJ. Recent advances in the diagnosis and management of cluster headache. BMJ. 2022 Mar 16;376:e059577.
2. NICE. Headaches in over 12s: diagnosis and management. Clinical guideline CG150. Published September 2012, Last updated June 2025.
3. May A, Evers S, Goadsby PJ, et al. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol. 2023 Oct;30(10):2955-79.
4. Robbins MS, Starling AJ, Pringsheim TM, et al. Treatment of cluster headache: the American Headache Society evidence-based guidelines. Headache. 2016 Jul;56(7):1093-106.
5. Ruscheweyh R, Broessner G, Goßrau G, et al. Effect of calcitonin gene-related peptide (-receptor) antibodies in chronic cluster headache: results from a retrospective case series support individual treatment attempts. Cephalalgia. 2020 Dec;40(14):1574-84.
6. Fontaine D et al. Anatomical location of effective deep brain stimulation electrodes in chronic cluster headache. Brain. 2010 Apr;133(Pt 4):1214-23.
7. Goadsby PJ et al. ACT2 Study Group. Non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: A randomized, double-blind, sham-controlled ACT2 study. Cephalalgia. 2018 Apr;38(5):959-969