Clinical reference · Card 09 of 11 · Treatment
Treatment — EAN 2023 recommendations
ACUTEAbort the attack
100% oxygen ≥12 L/min for 15 min via non-rebreather mask with reservoir — 78% pain-free at 15 min vs 20% for air (RCT, n=109)
Sumatriptan 6 mg subcutaneous — 74% improved at 15 min vs 26% placebo (RCT)
Zolmitriptan nasal 5–10 mg or sumatriptan nasal 20 mg if injection is not tolerated
TRANSITIONALCover the gap until prophylaxis works
Prednisone 100 mg for 5 days, then taper by 20 mg every 3 days — 7.1 vs 9.5 attacks in week 1 (RCT, n=118)
Greater occipital nerve block with steroid — RCT evidence of reduced attack frequency
PREVENTIVEStop the bout
Verapamil ≥240 mg/day, titrated — first-line. ECG before starting and before each dose increase (Card 10)
Lithium or topiramate as alternatives
Galcanezumab 300 mg monthly — episodic cluster headache only; the chronic trial did not meet its endpoint
REFRACTORYSpecialist territory
Non-invasive vagus nerve stimulation — efficacious for episodic, not chronic
Occipital nerve stimulation (ICON) and sphenopalatine ganglion stimulation for intractable chronic disease
Psilocybin remains investigational; no guideline recommends it
NOT RECOMMENDEDFor acute attacks
Oral triptans (too slow for a 15-minute peak), opioids, NSAIDs, paracetamol, ergots.
SOURCES May A, Evers S, Goadsby PJ, et al. Eur J Neurol 2023;30(10):2955–2979. Trials: Cohen 2009 JAMA; Sumatriptan Cluster Headache Study Group, NEJM 1991;325:322–6; Obermann 2021 Lancet Neurol; Goadsby 2019 NEJM.
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