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

  • See NICE CG150 “Headaches in over 12s: diagnosis and management”
  • 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 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 ouchuk.org
  • During a cluster, patients may suffer more than one attack daily and require up to 2 doses of sumatriptan in a 24 hour period
  • Patients with cluster headache may need to use up to 2 doses of sumatriptan per day throughout their cluster bout. Therefore triptan use should not be restricted to 2 days per week as recommended for migraine
  • If sumatriptan injections are unacceptable consider zolmitriptan nasal spray

Prophylaxis

ChoiceDrugDosage
1st choice
Verapamil 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. Once patients are on a stable dose ongoing ECG monitoring is recommended e.g. every 6 months

Prescribing Notes

  • See NICE CG150 “Headaches in over 12s: diagnosis and management”
  • Prophylaxis is indicated during a cluster of attacks (approximately 1-3 months) and should be withdrawn one month after headaches cease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