Medical Therapies for Cluster Headaches

Diagnosing a headache is one challenge, but finding a treatment regimen that works for an individual, can be equally if not more tricky. For cluster headaches, there are a number of abortive and preventive medications, as well as some novel therapies – for those people who do not respond to medication.  Let's review these treatments below.

Acute Medications

Oxygen is one type of acute treatment used in cluster headaches.

The dose is typically 100% oxygen inhaled at 7-10L/min for 15-20 minutes. One promising aspect of oxygen is that there is virtually no side effects. On the other hand, the availability of an oxygen tank at any moment, and the hassle of carrying one around, can be burdensome.

Triptans, especially sumatriptan (Imitrex) and zolmitriptan (Zomig), have been found to be effective for relieving cluster headaches. The doses are typically 6mg of subcutaneous – injected with a needle in the fatty tissue – sumatriptan, 20mg of sumatriptan intranasally, or through the nose, or 5-10mg of zolmitriptan intranasally. As with all triptans, these drugs should be avoided in pregnancy and in people with heart disease and uncontrolled high blood pressure. Side effects of triptans include: nausea, paresthesias, fatigue and chest or throat tightness.

Dihydroergotamine (D.H.E. 45, Migranal) is an option – although rarely used – to alleviate cluster headaches.

  Intravenous – or through the vein – administration is thought to be the most effective – although, this is limiting due to the short duration of cluster attacks. Dihydroergotamine cannot be used along with triptans, in pregnancy, or in individuals with poorly controlled blood pressure and/or heart disease.

Lidocaine may provide moderate relief for cluster headaches and is sometimes used in combination with sumatriptan. Lidocaine is given by nasal drops, with the person lying down with his head  the turned to the side of pain.

Octreotide  –  a medication that is similar to the hormone somatostatin – is a potential option for individuals with heart disease and cluster headaches, as its use is not contraindicated in these patients. Somatostatin is a hormone that inhibits the release of substance P – a protein involved in pain regulation. Side effects of octreotide include injection side pain, nausea, abdominal discomfort and high sugar levels.

Preventive Medications

Verapamil is a medication used to treat high blood pressure, but is also used to prevent cluster headaches. While on verapamil, your doctor will monitor your heart rate and rhythm. Constipation is the most common side effect of verapamil.

Lithium is usually chosen secondarily to verapamil due to its multiple drug interactions, and potential side effects for toxicity and harmful effects on the kidney and thyroid.

Side effects may include diarrhea, tremor, and increased urination.

Topiramate (Topamax) is another second-line therapy for prevention of cluster headaches. Side effects may include: weight loss, fatigue, dizziness, paresthesias, cognitive dysfunction, and taste alteration.

Other preventive treatments include anti-seizure medications like Gabapentin (Neurontin) and Valproic acid – which may cause side effects like weight gain and fatigue. Valproic acid also requires blood test monitoring, especially of the liver.

Botulinum toxin – known by the trade name Botox – works by blocking nerve connections. One 2007 study in The Journal of Headache and Pain found that Botox may be beneficial as a preventive add-on therapy for a limited number of patients with chronic cluster headaches.

Corticosteroids – like prednisone – can be used to gain control of a cluster headache and provide a short-term preventive care plan. Unfortunately, it is common for headaches to recur as the prednisone wears off.

What If I Don't Respond to Medication?

Patients who still have cluster headaches despite medication may need  a more invasive treatment,  like certain nerve blocks or deep brain stimulation. These emerging procedures carry their own risks and need careful consideration by you, your doctor, and your surgeon.

Take-Home Points

• Cluster headaches are excruciatingly painful headaches for which there are both acute and preventive treatment options available.

• While the majority of cluster headache sufferers respond to a a regimen of medications, more invasive procedures like deep brain stimulation or nerve blocks may be considered – although they do carry their own risks.

• Be an advocate for your health and be candid with your neurologist or headache specialist about your cluster headache therapies. Gain control over these debilitating headaches and maximize your quality of life.


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Sostak P, Krause P, Förderreuther S, Reinisch V, & Straube A. Botulinum toxin type-A therapy in cluster headache: an open study. J Headache Pain. 2007 Sep;8(4):236-41.

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DISCLAIMER: The information in this site is for informational purposes only. It should not be used as a substitute for personal care by a licensed physician. Please see your doctor for advice, diagnosis, and treatment of any concerning symptoms or medical condition.

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