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CLUSTER HEADACHES: for description see Clinicians Corner Dated May 7,2020


Oxygen:  Flow rate is 12 liters per minute inhaled through a mask, sitting upright is safe and inexpensive, and works within 15 minutes.  However, Medicare will NOT pay for oxygen for treatment of episodic cluster headache, even though it is the standard of care. (Fortunately for most, oxygen therapy is affordable.)

Fast acting triptan: such as injectable sumatriptan (Imitrex) , or sumatriptan nasal spray, or zolmitriptan (Zomig) nasal spray.  Sumatriptan injection and nasal spray are available as generics. Zomig is brand only.

Ergotamine preps: same as migraine dosage.  Will help some patients.  Save for patients who can’t use a triptan. Same dosage as migraines

  • Migranal® (dihydroergotamine) nasal spray 4mg/ml.
  • H.E. ® (dihydroergotamine) injection

Octreotide may be effective in the treatment of acute cluster headaches.

Butorphanol: (Staldol® nasal spray) C-IV

  • Narcotic administered as a nasal spray. May provide relief esp. if nausea.
  • Side effects: watch for drowsiness, may be habit forming.

Lidocaine:   Some success with intranasal Lidocaine. Lidocaine is hard to administer, and mixed results (33% efficacy).


Calcium channel blockers: Verapamil is the drug of choice. Use highest tolerable dose. Watch for changes in heart rhythm and slowing of the heart. Best to do an ECG before starting therapy.

Watch for:  swelling, gastrointestinal discomfort, constipation, dull headache.

Lithium: can be used but save for patients not responding to verapamil.

Be sure to inform patient about side effects:

  • Drink 8 to 12 glasses of water a day. Watch for dehydration.
  • Take with food to minimize GI upset.
  • Blood levels need to be checked

Prednisone- can be effective. Reserve for patients who don’t respond to verapamil. Start high dose, and taper over a few weeks.

Melatonin: can help some patients. 10mg in the evening.  This makes sense because melatonin levels are decreased in some patients with cluster headache.

Anticonvulsants: Gabapentin (Neurontin®), Topiramate (Topamax®), and Divalproex (Depakote ER®) have all shown promise.  Use doses as for migraine prophylaxis.

Emgality (galcanezumab)

Emgality is a calcitonin gene-related peptide (CGRP) antagonist indicated in adults for

  • Preventive treatment of migraine AND
  • Treatment of episodic cluster headache (approved June 2019)

NOTE: inform patients continue preventative treatment for 4 to 6 weeks after remission, to make sure cycle has ended

Cluster headaches, mostly seen in men are extremely painful and challenging to treat and prevent.  Your Thompson Pharmacist is a great resource to help your doctor come up with the best and most affordable treatment options. Go Ahead and ASK… at Thompson Pharmacy it’s ALL for YOU!