4.7.4.3 Drug treatment of cluster headache

Acute attacks

ChoiceDrugDosage
1st choiceSumatriptan subcutaneous injection 6mg/0.5ml syringeDose:
By subcutaneous injection, 6mg as soon as possible after onset (patient not responding should not take second dose for same attack); dose may be repeated once after not less than 1 hour if headache recurs; max 12mg in 24 hours

Prescribing Notes

  • NICE Clinical Guideline 150 entitled “Diagnosis and management of new onset headaches in young people and adults” was published in September 2012.
  • Cluster headache management is usually better left to experienced specialists who see this disorder frequently.
  • Analgesics have no place in treating cluster headache. Ergotamine tartrate, and all orally-administered triptans are of no use as acute therapy.
  • High flow oxygen (100% at 7-12 L/min for 10-15 minutes at onset of attack) is a useful addition to subcutaneous sumatriptan. The oxygen is administered through a high flow regulator and tight fitting mask. A tight fitting non-rebreathing mask should be used. Information on availability of suitable masks and loan of appropriate regulator equipment is available from OUCH UK.
  • During a cluster, patients may suffer more than one attack daily and require up to 2 doses of sumatriptan in a 24 hour period.

Prophylaxis

ChoiceDrugDosage
1st choiceVerapamil tablets 40mg, 80mg, 120mg, 160mg [unlicensed indication; under specialist supervision]Dose:
240-960mg daily in 3-4 divided doses. A baseline ECG should be performed before initiating treatment, and repeated with each dose escalation over 80mg twice daily

Prescribing Notes

  • NICE Clinical Guideline 150 entitled “Diagnosis and management of new onset headaches in young people and adults” was published in September 2012.
  • Prophylaxis is indicated during a cluster of attacks (approximately 1-3 months) and should be withdrawn one month after headaches cease.
  • Most patients will require specialist advice.