Clu st er Headach e M an agem en t

Characteristically, headaches are:

- Unilateral ABBREVIATIONS:
- Excruciating
NS: nasal spray
- Sharp, piercing, throbbing, or Adult patient with
burning SC: subcutaneously
definite diagnosis of
- Rapid onset and progress over SPG: sphenopalatine ganglion
cluster headache
a few minutes
- 15?180 minutes duration
- Often with autonomic signs,
restlessness, agitation

Monitor for
Does recurrence of
Is
patient cluster
patient having
No require prophylactic No
an acute cluster
treatment? Provide treatment
attack?
plan for acute
cluster attack

Yes
Yes

Initiate acute therapy with ?1 Initiate 1 of:

of: - Verapamil 360 mg/day orally in divided doses
Oxygen 100% at 6?12
- Oxygen - Melatonin 10 mg orally at bedtime
L/minute via high-flow
- Sumatriptan 6 mg SC or 20 - Lithium 900 mg/day orally in divided doses
mask with patient sitting
mg NS - Suboccipital corticosteroid injection
- Zolmitriptan 5?10 mg NS - Galcanezumab-gnlm 300 mg SC as 3
consecutive 100-mg injections at onset of
cluster period and then once monthly until end
of cluster period
Is
- Civamide 0.035% 100 mcL NS in each nostril
response (not available in the United States)
unsatisfactory No
(partial or Review lifestyle triggers for cluster headache,
none)? such as consumption of alcohol and
nitrite-containing foods and strong
odors/perfume
Yes

Continue
Add 1 of:
prophylactic
- Octreotide 100 mcg SC Are initial
treatment
(single dose) prophylactic No
- Lidocaine 10% NS treatments
Provide
- Other acute therapy not ineffective?
treatment plan
previously tried
for acute attack

Yes

Consider trial of:

- Other prophylactic agent not
previously used
- Noninvasive vagus nerve
stimulation
- Invasive procedure such as:
- SPG stimulation
- Radiofrequency ablation of
SPG
- Occipital nerve stimulation
- Gamma knife radiosurgery
to trigeminal nerve root

REFERENCES: Curr Neurol Neurosci Rep. 2021 May 5;21(7):31 - Lancet Neurol. 2018 Jan;17(1):75?83 -
Headache. 2016 Jul;56(7):1093?1106 - BMJ. 2012 Apr 11:344:e2407
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