Treatment

Acute treatment

• First-line

  • Oxygen therapy with FiO2 100%: usually the first choice if available

  • Triptans

    • Subcutaneous sumatriptan

    • Or intranasal zolmitriptan

Standard analgesics (e.g., acetaminophen, NSAIDs, opioids) are not recommended because they are ineffective and may lead to medication overuse headache if used frequently.

To improve absorption, apply nasal sprays in the nostril unaffected by congestion.

• Prophylactic agents

  • Verapamil: first choice

  • If verapamil is ineffective or not tolerated, consider either of the following:

    • Lithium

    • Melatonin

    • Emerging therapies: e.g., galcanezumab , civamide

• Transitional treatment options: Consider as a bridge therapy until prophylactic agents become effective.

  • Suboccipital steroid injections

  • Short-term glucocorticoids: e.g., prednisone or methylprednisolone

Transitional therapy with shorter onset latencies may be necessary until prophylactic treatment takes effect.

Neuromodulation is usually reserved for cluster headache refractory to multiple medical treatments.

• Noninvasive neurostimulation: noninvasive vagus nerve stimulation

• Invasive neurostimulation: e.g., sphenopalatine ganglion stimulation and occipital nerve stimulation