Drug Treatment of Cluster Headache

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

Patients presenting with a first bout of suspected cluster headache should be referred to a specialist for confirmation of diagnosis.

Smoking and alcohol may be trigger factors for cluster headache and patients should be given advice on reducing alcohol intake and smoking cessation as appropriate.

All patients should be advised on the risk of medication-overuse headache and overuse of acute medicines should be addressed.  See migraine section for further information.

There is no evidence to support the use of opioids, NSAIDs, paracetamol or oral triptans in the management of confirmed cluster headache.

Useful links

NICE Clinical Guideline Headaches in over 12s: Diagnosis and Management [CG 150]

Organisation for the Understanding of Cluster Headache (OUCH)

Acute Attack of Cluster Headache

Specialist initiation (S1)

SUMATRIPTAN nasal spray

  • Dose: Initially 10–20 mg administered into one nostril.
  • If there is no response to the first dose, a second dose should not be taken for the same attack.
  • If headache recurs a second 10-20mg dose can be administered.
  • This should not be taken within 2 hours of the initial dose.
  • Maximum dose in 24 hours is 40mg.

SUMATRIPTAN 6mg/0.5ml solution for injection pre-filled pen

  • Dose: A single 6 mg subcutaneous injection for each cluster attack.
  • The maximum dose in 24 hours is two 6 mg injections (12 mg) with a minimum interval of one hour between the two doses.

Specialist use only (S2)

Short burst oxygen therapy (100% oxygen)

  • 100% oxygen at a rate of 10-15 litres/minute for 10–20 minutes is useful in aborting an attack.
  • Oxygen treatment is initiated by a Consultant Neurologist.
  • The home oxygen service is provided under a national contract managed by Health Facilities Scotland. 

Prophylaxis of Cluster Headache

Specialist initiation (S1)

VERAPAMIL

  • Unlicensed use.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.