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This tool is educational and informational. It does not replace clinical judgment. Verify cluster headache acute and prophylactic treatment selection, oxygen protocols, and verapamil monitoring against the cited source before acting.
Not prospectively validated. No clinical tool replaces bedside assessment.
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Tarvinder Singh, MD -- Vascular Neurologist. March 2026.
Cluster Headache Management
Separates attack relief, bridge therapy, and prevention by phase, subtype, and safety constraints. Includes oxygen and verapamil bedside protocols. Grounded in AHS 2016 and trial evidence.
Evidence level key (AHS grading)
Level A -- Established as effective.
Level B -- Probably effective.
Level C -- Possibly effective.
Level U -- Insufficient evidence.
Step 1: Quick Cluster Intake
Start with subtype, phase, oxygen, and PR interval
Cluster subtype
Subtype matters most for galcanezumab and lithium.
Current phase
Phase separates attack treatment from bridge therapy and prevention.
High-flow oxygen
If oxygen is unavailable, the acute path narrows quickly.
PR interval
Check before starting or escalating verapamil.
Step 2: Safety and Fit Modifiers
Acute safety blockers
These most often change what can be used right away during an attack.
Prevention fit
Use these when they materially change the prevention path.
At a glance
Start with subtype, current phase, oxygen availability, and PR interval. Those four details separate attack relief, bridge therapy, and prevention quickly.
Closest paths now: High-Flow Oxygen (100%) | Sumatriptan SC | Zolmitriptan Nasal.
Next
Use the protocol cards below whenever oxygen access or verapamil monitoring is likely to shape the next step.
Attack protocol
Oxygen attack-relief protocol
Use for active attacks.
Flow rate
12-15 L/min
Interface
Non-rebreather mask (not nasal cannula)
Duration
15-20 minutes per attack
Position
Sit upright and lean slightly forward
Expected response
Pain-free within 15 minutes in ~78% of attacks
Prevention protocol
ECG monitoring for verapamil
ECG review is required before titration.
Starting dose
240 mg/day divided TID
Typical target range
480-960 mg/day
- 1.Obtain a baseline ECG before starting verapamil.
- 2.Repeat the ECG 10 days after every dose increase.
- 3.Hold escalation if PR interval is >200 ms or there is new heart block.
Common dose-escalation path
240 mg/day -> 360 mg/day -> 480 mg/day -> 720 mg/day -> 960 mg/day
Evidence
High-Flow Oxygen (100%)
Level AResponse within 15 min in ~78% of attacks. Use non-rebreather mask, NOT nasal cannula. Patient should sit upright and lean forward. Keep O2 tank accessible during bout season.
Sumatriptan SC
Level AFastest triptan onset (~10 min). Autoinjector preferred for self-administration during attacks. Response rate >75%. Can use alongside O2.
Verapamil
Level BFirst-line prophylaxis for both episodic and chronic cluster. ECG required before starting AND at each dose increase (PR interval monitoring). Takes 2-3 weeks to reach therapeutic effect — needs transitional therapy bridge.
High-Flow Oxygen (100%)
Inhaled gas
12-15 L/min via non-rebreather mask for 15-20 min
Response within 15 min in ~78% of attacks. Use non-rebreather mask, NOT nasal cannula. Patient should sit upright and lean forward. Keep O2 tank accessible during bout season.
More bedside detail
Cautions: Severe COPD — monitor for CO2 retention (rare at short duration)
How to use it: Non-rebreather mask at 12-15 L/min. Some patients benefit from demand-valve O2 at higher flow rates (up to 15 L/min). Duration: 15-20 min per attack.
Sumatriptan SC
Triptan (5-HT1B/1D agonist)
6 mg SC — max 2 injections/24h, separated by ≥1 hour
Fastest triptan onset (~10 min). Autoinjector preferred for self-administration during attacks. Response rate >75%. Can use alongside O2.
More bedside detail
Cautions: Max 2 doses/24h Separate from ergots by 24h
How to use it: Inject into thigh or upper arm. Autoinjector available. Max 12 mg/24h.
Zolmitriptan Nasal
Triptan (5-HT1B/1D agonist)
5 mg intranasal — may repeat once after 2 hours
Alternative for patients who cannot tolerate SC injection. Onset ~15-20 min. Less effective than SC sumatriptan but better tolerated.
More bedside detail
Cautions: Separate from ergots by 24h
How to use it: Spray into one nostril (ipsilateral to pain if possible). Sit upright.
Prednisone Taper (Transitional)
Corticosteroid
60-80 mg/day × 5 days, then taper over 2-3 weeks
Bridge therapy while verapamil titrates to therapeutic dose. Rapid onset (days). Not for long-term use — max 3 weeks. Effective for bout suppression while maintenance prophylaxis takes effect.
More bedside detail
Cautions: Diabetes — monitor glucose Avoid prolonged use (>3 weeks) GI bleeding risk — consider PPI Insomnia common during taper
How to use it: Take in morning with food. Short course only — taper required. Monitor blood glucose in diabetics.
Greater Occipital Nerve Block
Peripheral nerve block
2-3 mL bupivacaine 0.5% + methylprednisolone 80 mg, ipsilateral
Effective transitional therapy. Can reduce attack frequency within days. Ipsilateral injection preferred. May need to repeat every 4-6 weeks during bout.
More bedside detail
Cautions: Transient occipital numbness expected Rare: alopecia at injection site
How to use it: Inject at the medial third of the superior nuchal line, ipsilateral to cluster side. 25G needle.
Verapamil
Calcium channel blocker
Starting 240 mg/day divided TID, titrate to 480-960 mg/day
First-line prophylaxis for both episodic and chronic cluster. ECG required before starting AND at each dose increase (PR interval monitoring). Takes 2-3 weeks to reach therapeutic effect — needs transitional therapy bridge.
More bedside detail
Cautions: ECG required at baseline and each dose escalation Heart block risk at high doses Constipation common
How to use it: Baseline ECG, repeat ECG 10 days after each dose increase. Monitor for constipation, ankle edema. Extended-release formulation preferred for compliance.
Galcanezumab (Emgality)
CGRP monoclonal antibody
300 mg SC at onset of cluster bout (3 × 100 mg injections)
Only FDA-approved treatment specifically for episodic cluster headache (2019). NOT approved for chronic cluster — phase 3 trial failed. Give 300 mg at bout onset. Significant reduction in weekly attack frequency.
More bedside detail
Cautions: Episodic cluster ONLY — no evidence for chronic cluster Injection site reactions common
How to use it: Three 100 mg SC injections at onset of cluster period. Injected in abdomen, thigh, or upper arm. Self-administered.
Subtype note: FDA-approved for episodic cluster headache ONLY. Phase 3 trial in chronic cluster was negative (Dodick et al. 2020, PMID: 32050782).
Lithium Carbonate
Mood stabilizer
300 mg BID-TID, target serum level 0.4-0.8 mEq/L
Second-line for chronic cluster headache (more evidence in chronic than episodic). Narrow therapeutic index — requires serum monitoring. Check renal function, thyroid, and serum levels regularly.
More bedside detail
Cautions: Narrow therapeutic index Monitor TSH — hypothyroidism risk NSAID interaction — increases lithium levels Dehydration risk
How to use it: Serum lithium levels at 5-7 days, then monthly. Monitor renal function and TSH every 6 months. Dehydration risk — counsel adequate hydration.
Subtype note: Stronger evidence in chronic cluster headache than episodic.
Opioids
Opioid
N/A — avoid in cluster headache
Must Not Offer. Ineffective for cluster headache. Risk of dependency especially with frequent attacks during bout. Can worsen attack frequency.
Oral Triptans
Triptan (oral formulations)
N/A — avoid in cluster headache
Onset too slow (30-60 min) — cluster attacks peak rapidly. SC or nasal routes required for clinically useful onset.
Erenumab (Aimovig)
CGRP receptor monoclonal antibody
N/A — not effective for cluster headache
CHERUB01 Phase 3 RCT (2025) was negative for chronic cluster headache — erenumab did not reduce weekly attack frequency vs placebo. Do not use for cluster headache prevention.
More bedside detail
Subtype note: CHERUB01 (2025): Phase 3 RCT in chronic cluster was NEGATIVE — no significant reduction in weekly attack frequency vs placebo.
Eptinezumab (Vyepti)
CGRP ligand monoclonal antibody
N/A — not effective for episodic cluster headache
ALLEVIATE Phase 3 RCT (2025) was negative for episodic cluster headache — eptinezumab did not reduce weekly attack frequency vs placebo. Do not use for cluster headache prevention.
More bedside detail
Subtype note: ALLEVIATE (2025): Phase 3 RCT in episodic cluster was NEGATIVE — no significant reduction in weekly attack frequency vs placebo.