Approach to acute and preventive management of cluster headache

Elizabeth Leroux, MD, FRCP, University of Calgary, Canada, gives an overview of current acute and preventive treatment options for cluster headache. The management process is initiated by a correct diagnosis, a task which can take years to complete. Then, cluster headache must be differentiated between its episodic and chronic forms. The severe pain can be treated using fast-action triptans such as zolmitriptan nasal spray or injectable sumatriptan, or with high flow rate 100% oxygen at 10-15L/min, both of which quickly combat symptoms unlike orally ingested medications. These treatment options, however, can be expensive or difficult to access in different countries with varying levels of healthcare support. Evidence is limited for the optimal preventive approach in cluster headache. Verapamil is the typical first line option. Corticosteroids are effective to bridge the time interval in new bouts of episodic cluster headache or chronic cluster headache until preventive drug therapy becomes effective but rebound symptoms and long-term side effects must be carefully considered. Encouragingly, galcanezumab, a CGRP monoclonal antibody, was recently approved by the FDA as the first treatment to reduce the frequency of episodic cluster headache attacks. This interview took place at the World Congress of Neurology (WCN) 2023 in Montreal, Canada.
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