Acute attacks
| Choice | Drug | Dosage |
|---|---|---|
| 1st choice | Sumatriptan subcutaneous injection 6mg/0.5ml syringe | Dose: 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 oxygen and other treatments for cluster headache 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
| Choice | Drug | Dosage |
|---|---|---|
| 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- Prophylaxis is indicated during a cluster of attacks (approximately 1-3 months) and should be withdrawn one month after headaches cease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