Patient information from BMJ

Cluster headaches: what treatments are available?

Last published:Sep 14, 2022

Cluster headaches are attacks of very severe pain, usually on one side of the head only. They can happen up to several times a day over a period of several weeks.

Standard painkillers, such as paracetamol, aren’t useful for cluster headaches, because they take too long to start working. But specialist treatments can help prevent and treat them.

You can use our information to talk with your doctor about the best treatments for you.

What treatments are available?

As the name suggests, cluster headaches are brief but very severe headaches that happen in clusters, sometimes more than once a day, over several weeks.

An episode of cluster headache can last between 15 minutes and three hours. The frequency of the attacks can vary from one every two days to eight times a day.

The period of time when the headaches happen is called the cluster period. It can vary from one week to one year. But in most people it lasts two or three months.

At the end of a cluster period, most people go for at least three months, and sometimes for years, without headaches. This period without headaches is called remission.

Treatment for cluster headaches aims to:

• relieve the pain of the attacks as quickly as possible, and

• prevent other attacks for the length of the cluster period, or at least make these attacks less severe.

In people who have chronic cluster headaches (when there are no periods of remission), the aim is to prevent attacks, or to make them less severe, over longer periods.

Fast pain relief for attacks

Triptans

The main treatment to quickly relieve the pain of cluster headaches is medicines called triptans.

You take these medicines either as a pain-killing injection or, if you don’t want to give yourself injections, as a nasal spray.

Injections and sprays are used because they work much more quickly than tablets. Most people find that their pain stops about 15 minutes after a triptan injection. Injections seem to work better than nasal sprays for many people.

If you use the injections, you keep them with you for when you need them. You can safely give yourself up to two injections each day.

Oxygen

Another treatment that can work well to relieve the pain of cluster headaches is oxygen. Breathing 100 percent oxygen through a mask for about 15 minutes relieves the pain of an attack in most people.

Your doctor will explain to you how to get the oxygen and the equipment you will need, and how to keep it safely at home.

Preventing attacks

Medicines

Several different medicines can be used to help prevent cluster headaches. One medicine that seems to work well for many people is called verapamil.

This medicine is usually used to treat heart conditions. So your doctor will want to check your heart before prescribing it, to make sure that it’s safe for you to take.

The idea is that you start to take it when you begin to have cluster headaches. After you have been free of headaches for two weeks, you gradually reduce the dose down to nothing.

It’s important not to take verapamil for longer than you need to, as it can cause side effects in some people.

If verapamil doesn’t help you enough, or if you have problems with side effects, there are other medicines that you can try. One of these is called valproate. Pregnant women should not take valproate, as it causes severe birth defects.

Transitional treatment

It can take several weeks for the medicines that prevent attacks to work properly. So your doctor might suggest what’s called transitional therapy.

This means taking extra medicines to help control your symptoms until the prevention medicines are working fully.

For example, one commonly used transitional treatment is steroids (the full name is corticosteroids). These medicines help reduce inflammation (swelling) around the nerves, which in turn helps to reduce pain.

If your doctor suggests this treatment, it will only be for a short time, as corticosteroids can cause serious side effects if you take them for too long.

Another transitional treatment is a nerve block. This is an injection of a drug that stops some nerves from sending pain signals to your brain.

Nerve blocks can also be used every few months to help treat chronic cluster headaches.

Surgery

There are two types of surgery that are sometimes used when other treatments haven’t worked.

They are called occipital nerve stimulation and deep brain stimulation. They both involve implanting small devices under the skin. These devices send mild electrical pulses to the nerves that can help reduce the pain of cluster headaches.

As with any type of surgery, these operations carry risks, such as infections. If you discuss these treatments with your doctor, he or she should carefully explain these risks.

What to expect in the future?

Cluster headaches can be difficult to live with. They are extremely unpleasant, and treating them can be complicated and troublesome to manage.

Some people suffer from depression as a result of having cluster headaches. If you find yourself becoming depressed, don’t keep these feelings to yourself. Talk to your doctor, and to family and friends.

But there is some good news:

• cluster headaches don’t lead to any long-term physical problems. For example, unlike some types of headache, they’re not a possible sign of something more serious, and

• in many people the symptoms become less severe as they get older.

When you first start treatment you should be seen by a neurologist. Neurologists specialise in conditions like cluster headaches that affect the nervous system. Your usual doctor might also want to check how you’re doing from time to time.

Your doctor might also be able to put you in touch with a support group.

For example, in the UK, the Organisation for the Understanding of Cluster Headache (ouchuk.org) offers support and guidance for people living with cluster headaches and their families.