What should I try first if I've just been diagnosed?

The standard first-line stack has three parts:

An abortive to stop individual attacks. The two first-line options are 100% oxygen at 15 L/min or higher via a non-rebreather mask (or demand valve), and sumatriptan injections. DMT is a third option that many patients find effective, though it isn't yet in clinical guidelines. Use whatever you have at the very first sign of an attack. The abortive chapter covers these in detail.
A preventive to reduce how many attacks come in the first place. Verapamil is the usual choice, started at 80 mg three times a day and raised gradually with ECG monitoring. Galcanezumab (Emgality, 300 mg a month) is also approved as a cluster preventive in many countries, but only for episodic cluster headache. Certain psychedelics at low doses can also be effective. The preventive chapter covers these.
A bridge to suppress attacks while a longer-acting preventive ramps up. The usual choices are an oral prednisone taper or a greater occipital nerve block at the start of the cycle. The bridge chapter covers these.

Don't start with NSAIDs, oral triptan pills, or opioids. None of them work for cluster headache attack. If your doctor leads with those, it's a sign they may not be familiar with current cluster headache guidelines. See our chapter on common treatment mistakes.

Is it normal to need multiple treatments at once?

Yes. The standard of care has three parts (abortive + preventive + bridge), and most patients might need all three. A typical day in an active cycle looks like this: oxygen (or sumatriptan or DMT) ready to stop attacks, verapamil taken on a daily schedule to prevent attacks, and a steroid taper or nerve block during the first weeks of the cycle.

In treatment-resistant chronic cluster headache, doctors routinely combine verapamil with lithium and melatonin.

How is episodic cluster headache treated differently from chronic?

Episodic cluster headache comes in cycles (clusters), a period of daily attacks lasting weeks to months, followed by a remission period with no attacks. Chronic cluster headache patients, on the other hand, get attacks all year long with almost no breaks. About 85–90% of patients have the episodic form.

The abortive treatments are the same for episodic and chronic patients.

The preventive treatments differ:

Episodic. Preventives are taken only temporarily. Patients start them at the beginning (or ideally shortly before the start) of a cycle and taper them off once they've been attack-free for a few weeks. Galcanezumab and the gammaCore vagus nerve stimulator can also be effective.
Chronic. Preventives are taken indefinitely. Verapamil works for about 56% of patients, lower than in episodic. Galcanezumab and gammaCore don't work for chronic cluster headache; their trials in chronic patients were negative. Lithium becomes more important. Patients who don't respond to any of the usual treatments may be candidates for implanted devices that send mild electrical pulses to specific nerves or deep brain structures.

Bridge treatments also differ:

Episodic. A steroid taper or greater occipital nerve block at cycle onset is standard.
Chronic. There is no cycle start to bridge to, and repeated steroid courses aren't sustainable long-term. Greater occipital nerve blocks can still be used periodically, but they play a more limited role.

What if nothing works?

Before deciding nothing works, double-check the basics in our chapter on common treatment mistakes.

If you've genuinely tried all that and still aren't getting relief, the next steps are:

Repeat greater occipital nerve blocks every four to eight weeks.
Ask for a referral to a specialist headache center. Patients with treatment-resistant chronic cluster headache may be candidates for deep brain stimulation or occipital nerve stimulation, implanted devices that deliver mild electrical pulses to specific brain or nerve structures. They may also be eligible for experimental treatments.

Many patients have suicidal thoughts during active cycles — the condition is sometimes called "suicide headache." If you're in that place, please reach out to a doctor, a patient support group, or a crisis line. Resources are listed here.

Why don't most doctors know about effective cluster headache treatments?

Cluster headache is rare. About 1 in 1,000 people will have it in their lifetime, which means a typical general practitioner sees only one or two cases across an entire career. The condition is also underrepresented in medical training. Patients often wait for years for the right diagnosis, often misdiagnosed in the meantime as migraine, sinus problems, dental pain, or tension headache.

Oxygen-specific knowledge is particularly weak: many doctors don't know the correct prescription wording, and some don't realize high-flow oxygen is the international first-line acute treatment.^[1]^[2]

Why hasn't my doctor offered me oxygen?

Two reasons usually combine. First, many doctors (including some neurologists) aren't familiar with cluster headache treatment. Second, oxygen prescribing has practical barriers that vary by country. In some places, public insurance or national health services don't reliably cover home oxygen for cluster headache, and some oxygen suppliers refuse to fill the prescription for fear of losing their contract.

In a survey of more than 2,000 cluster headache patients worldwide, only 49% had access to oxygen, even though it's the safest and most effective abortive treatment available. About 44% of patients had to suggest oxygen to their doctor themselves, and 12% of doctors refused outright.^[3]

If your doctor hasn't offered oxygen, bring it up directly. If they push back, ask for a referral to a headache specialist or to a neurologist who treats cluster headache regularly. See our guide on how to get a prescription for oxygen.

How do I get oxygen prescribed?

See our guide on how to get a prescription for oxygen.

How is cluster headache treated during pregnancy or breastfeeding?

The treatment list shrinks, but it isn't empty. High-flow oxygen remains the first-line abortive: it is safe in pregnancy and breastfeeding, has no fetal exposure, and works as well as it does outside pregnancy. Intranasal lidocaine and a single greater occipital nerve block are also considered safe acute or bridging options under specialist supervision.^[4]

A few medications can be used with caution and only when the benefit clearly outweighs the risk:

Short courses of corticosteroids (oral prednisone or a GON block with steroid) are sometimes used to break a severe bout, but oral steroids slightly raise the risk of congenital malformations in the first trimester and can affect fetal growth later. Discuss this carefully with both your headache specialist and obstetrician.
Triptans are not formally approved in pregnancy, but registry data on sumatriptan in particular do not suggest a clear increase in birth defects. Some specialists consider triptans on a case-by-case basis when oxygen alone isn't enough.^[4]^[5]

Several common cluster medications should not be used during pregnancy:

Verapamil at high doses, lithium, topiramate, valproate, ergotamine, and DHE are all either teratogenic, linked to fetal harm, or insufficiently studied in cluster headache pregnancies.
CGRP monoclonal antibodies (galcanezumab and others), botulinum toxin, neuromodulation devices, and psychedelics have no pregnancy safety data in cluster headache and are not recommended.

Many cluster medications also pass into breast milk. If you're breastfeeding, raise each medication with your obstetrician or a lactation specialist before using it. As with any medication question in pregnancy, the right answer is usually a joint conversation between your headache specialist and obstetric team.

How is cluster headache treated in children?

Cluster headache in children is rare, often misdiagnosed as migraine, and rarely studied in clinical trials. There are no pediatric-specific cluster headache guidelines, so treatment is adapted from the adult literature and individualized.

For acute attacks, high-flow oxygen and intranasal sumatriptan are considered first-line in children, just as in adults. Subcutaneous sumatriptan is used less often in young children but can be considered for severe attacks at an age-appropriate dose, under specialist supervision.

For prevention, verapamil is the preferred option, again with ECG monitoring before starting and at each dose increase. Other preventives sometimes used off-label in children include melatonin, gabapentin, topiramate, valproic acid, and indomethacin. A greater occipital nerve block is a reasonable bridging option for children who can tolerate the injection.

Many of the more invasive treatments used in adults (deep brain stimulation, occipital nerve stimulation, CGRP antibodies, psychedelics) lack pediatric safety data and are not recommended outside of research settings. If your child has cluster headache, treatment should be coordinated by a pediatric neurologist or a headache specialist with pediatric experience.

References

↩ American Headache Society and American Migraine Foundation (2018). Joint statement on oxygen therapy for cluster headache. American Headache Society. Link
↩ Rozen TD (2017). Prescribing oxygen for cluster headache. Headache. Link
↩ Schor LI, Pearson SM, Shapiro RE, Zhang W, Miao H, Burish MJ (2021). Cluster headache epidemiology including pediatric onset, sex, and ICHD criteria: Results from the International Cluster Headache Questionnaire. Headache, 61(10), 1511–1520. Link
↩ Björk MH, Kristoffersen ES, Tronvik E, Egeland Nordeng HM (2021). Management of cluster headache and other trigeminal autonomic cephalalgias in pregnancy and breastfeeding. European Journal of Neurology, 28(7), 2443–2455. Link
↩ Saldanha IJ, Cao W, Bhuma MR, et al. (2021). Management of primary headaches during pregnancy, postpartum, and breastfeeding: a systematic review. Headache, 61(1), 11–43. Link

Frequently asked questions