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How does one treat cluster headaches?

Cluster headaches are one of the most painful conditions known to medicine. When you're in pain, you'll try almost anything to make it stop, but it's difficult to know what works and what doesn't. Many neurologists are still unfamiliar with treatment options, and it's easy to spend years on the wrong drugs before finding the right ones.

This guide is here to help you understand effective treatment options. It covers what works to reduce how many attacks you have (preventives), what works to stop an attack in progress (abortives), and what works to suppress attacks during a cycle while a given preventive starts to work (bridges). It also covers what patients use beyond standard care, what's worth trying, and what to avoid.

Ideally, you will use at least one preventive and one abortive treatment, used together. A preventive can reduce the frequency of your attacks significantly (or even help you skip a cycle entirely, especially if started just before it begins), while an abortive gives you a fast way to stop attacks as soon as they hit. At the start of a cycle, a bridge treatment can temporarily suppress attacks if the preventive hasn't kicked in yet.

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Essential treatments for cluster headaches

The standard of care has three components: a preventive (taken regularly to reduce how many attacks you have), an abortive (used to stop an attack in progress), and a bridge treatment (a fast-acting preventive used short-term at the start of a cycle while the long-term preventive ramps up). Most patients need at least the first two.

Preventives recommended by guidelines

• Verapamil is first-line. About 87% of patients get meaningful benefit, and up to 94% of episodic patients become attack-free at higher doses.
• Galcanezumab (Emgality) is the only FDA-approved cluster headache preventive (for episodic cluster headache only). 71% of patients get at least a 50% reduction in attacks.^[1]

Abortives recommended by guidelines

• High-flow oxygen: 78% of attacks pain-free or with adequate relief at 15 minutes in the landmark trial,^[2] and a 2022 network meta-analysis ranked it the top acute treatment overall.^[3] It's very safe, has no drug interactions, and should be every patient's first option.
• Subcutaneous sumatriptan injection: 75% of attacks respond within 15 minutes.^[4] Use it sparingly, because patients sometimes report increased attack frequency and intensity with frequent use, and a small case series found the same pattern.^[5]
• Both are first-line in every major guideline.^[6][7][8]

Bridges recommended by guidelines

• Oral prednisone taper: it works within 1-3 days and covers the gap until a preventive (for example, verapamil) takes effect. About a third of patients had ≥50% reduction in attacks at day 7 in the PREDCH trial.^[9]
• Greater occipital nerve block (GONB): it is a single steroid + anesthetic injection at the back of the skull. 85% of patients became attack-free at one week in a clinical trial.^[10] It is the only Level A preventive in AHS guidelines.

Beyond standard of care

Some treatments aren't in clinical guidelines but are widely used by patients and considered effective.

• Psilocybin and LSD as preventives. Patient surveys pooling more than 5,000 cluster headache sufferers consistently rate them as among the most effective preventives available, reaching around 75% reported efficacy.^[11] Clinical trial evidence is more limited but consistent: a randomized trial of psilocybin showed about a 50% reduction in attack frequency on repeat dosing,^[12] and the foundational case series from Harvard reported similar patterns.^[13] See the psychedelics guide for protocols, evidence, and safety.
• 5-MeO-DALT as a preventive. A lesser-known synthetic tryptamine, used by patients since around 2015 at small doses, with almost no hallucinogenic effects. It's still legal in many countries, and most regions don't punish possession for personal use, which makes it uniquely accessible. However, the formal evidence is thin. In a 46-patient self-published survey, 87% reported reduced attacks and 46% reported zero attacks following treatment.^[14] See the psychedelics guide for the full protocol.
• DMT as an abortive. Patients widely report that a few puffs from a DMT vape can stop an attack within seconds. However, no clinical trials exist yet (but one is underway). This treatment is currently being investigated at Yale School of Medicine. See the DMT guide for the full protocol, equipment, and safety.
• The Vitamin D3 "Batch" protocol as a preventive. A community-developed regimen: daily high-dose vitamin D3 (10,000 IU after a loading phase) plus cofactors (omega-3, magnesium, K2, calcium, A, zinc, boron). In a self-reported survey of 110 cluster headache patients, 80% reported significant reductions in attack frequency, severity, and duration.^[15] The regimen is cheap and over the counter, but the high D3 dose requires periodic blood-calcium monitoring. The full protocol is documented at vitamindregimen.com. See the preventive chapter for more details.

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Which cluster headache treatments will work for me?

Keep in mind that no single treatment works for everyone. Oxygen helps most patients but not all. Verapamil is well-tolerated by some and dangerous for others. The right combination of treatments is usually found by trial and error, with a doctor who understands cluster headaches.

Treatments also differ depending on whether you have episodic cluster headache (cycles separated by remission) or chronic cluster headache (continuous attacks all year long). Some preventives work for both. Some only work for one. This guide will help you understand these distinctions.

Finally, several effective treatments, such as psilocybin, LSD, and DMT, are illegal in most countries, and oxygen, though legal everywhere, is often difficult to get prescribed and delivered (but you can always buy it directly yourself).

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Cluster headache treatments at a glance

Type	What it does	Examples	When to use
Preventive	Reduces attack frequency over days to weeks	Verapamil, galcanezumab (Emgality, episodic only), lithium, psilocybin, LSD, 5-MeO-DALT, vitamin D3	Start at (or, ideally, just before) the beginning of a cycle
Abortive	Stops an attack in progress within minutes	High-flow oxygen, sumatriptan injection, DMT, zolmitriptan nasal spray, gammaCore (episodic only)	Use at the very start of every attack
Bridge	Suppresses attacks within days; covers the gap while a long-term preventive kicks in	Prednisone taper, greater occipital nerve block	Start at the beginning of a cycle

If you've just been diagnosed with cluster headaches (or you suspect you have cluster headaches) and aren't sure where to start, read stopping a cluster headache attack first. It covers the two treatments most likely to help right now: high-flow oxygen and sumatriptan. Our guide also covers treatments to avoid and common mistakes patients and doctors make.

Simultaneously, you should be thinking about which preventive to take, and whether a bridge treatment would be helpful, in consultation with your doctor.

Finally, there are some interventions that some patients report helping, but for which the evidence is much thinner and the reported efficacy is much lower than some of the treatments discussed so far. The chapter on home remedies covers the most popular and safest ones to try.

Keep in mind that ClusterInfo also has dedicated guides on high-flow oxygen, DMT, and psychedelics for prevention. Those cover protocols, equipment, safety, and drug interactions in great detail.

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References

1. ↩ Goadsby PJ, Dodick DW, Leone M, et al. (2019). Trial of galcanezumab in prevention of episodic cluster headache. New England Journal of Medicine, 381(2), 132–141. Link
2. ↩ Cohen AS, Burns B, Goadsby PJ (2009). High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA, 302(22), 2451–2457. Link
3. ↩ Medrea I, Christie S, Tepper SJ, Thavorn K, Hutton B (2022). Network meta-analysis of therapies for cluster headache: effects of acute therapies for episodic and chronic cluster. Headache. doi:10.1111/head.14283
4. ↩ Law S, Derry S, Moore RA (2013). Triptans for acute cluster headache. Cochrane Database of Systematic Reviews(7), CD008042. Link
5. ↩ Rossi P, Di Lorenzo G, Formisano R, Buzzi MG (2004). Sub-cutaneous sumatriptan induces changes in frequency pattern in cluster headache patients. Headache. Link
6. ↩ May A, Evers S, Goadsby PJ, Leone M, Manzoni GC, Pascual J, et al. (2023). European Academy of Neurology guidelines on the treatment of cluster headache. European Journal of Neurology, 30(10), 2955–2979. doi:10.1111/ene.15956
7. ↩ Robbins MS, Starling AJ, Pringsheim TM, Becker WJ, Schwedt TJ (2016). Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache, 56(7), 1093–1106. doi:10.1111/head.12866
8. ↩ National Institute for Health and Care Excellence (2021). Headaches in over 12s: diagnosis and management (CG150). NICE Clinical Guideline. Link
9. ↩ Obermann M, Nägel S, Ose C, et al. (2021). Safety and efficacy of prednisone versus placebo in short-term prevention of episodic cluster headache: a multicentre, double-blind, randomised controlled trial. Lancet Neurology, 20(1), 29–37. Link
10. ↩ Ambrosini A, Vandenheede M, Rossi P, et al. (2005). Suboccipital injection with a mixture of rapid- and long-acting steroids in cluster headache: a double-blind placebo-controlled study. Pain, 118(1-2), 92–96. Link
11. ↩ Rusanen SS, De S, Schindler EAD, Artto VA, Storvik M (2022). Self-reported efficacy of treatments in cluster headache: a systematic review of survey studies. Current Pain and Headache Reports, 26(8), 623–637. Link
12. ↩ Schindler EAD, Sewell RA, Gottschalk CH, Flynn LT, Zhu Y, Pittman BP, et al. (2024). Psilocybin pulse regimen reduces cluster headache attack frequency in the blinded extension phase of a randomized controlled trial. Journal of the Neurological Sciences, 460, 122993. doi:10.1016/j.jns.2024.122993
13. ↩ Sewell RA, Halpern JH, Pope HG Jr (2006). Response of cluster headache to psilocybin and LSD. Neurology, 66(12), 1920–1922. doi:10.1212/01.wnl.0000219761.05466.43
14. ↩ Post M (2015). Cluster headache patient survey: 5-MeO-DALT. Self-published.
15. ↩ Batcheller P (2014). Survey of cluster headache sufferers using vitamin D3. Neurology, 82(10 Supplement), P1.256. Link