Patient handout

Cluster Headache

PRODUCTION

1. Your condition

This handout is for cluster headache. Your care team identified this based on: severe unilateral orbital/periorbital pain (15–180 min) (ichd-3 pmid 29368949).

Other reasons your team may use this plan: ipsilateral lacrimation / conjunctival injection / rhinorrhea / ptosis / miosis (ichd-3 pmid 29368949); stereotyped attacks 1–8/day during a bout (ichd-3 pmid 29368949); existing ch on problem list (preventive titration) (aan 2010 robbins pmid 27432623).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
oxygen_high_flow	100% O2 12–15 L/min via non-rebreather mask × 15–20 min	inhaled	PRN per attack	Cohen JAMA 2009 (PMID 19996400) — 78% pain-free at 15 min; first-line, no contraindication including in pregnancy/CAD
sumatriptan	6 mg SC at attack onset	SC	q1h max 2 doses/24h	Most rapid effect (15 min); SC route preferred over PO for speed (AAN 2010 PMID 27432623)
zolmitriptan	5–10 mg IN	IN	PRN	Alternative when SC not available (AAN 2010 PMID 27432623)
octreotide	100 mcg SC	SC	PRN per attack	Triptan-CI pivot — Matharu Ann Neurol 2004 small RCT; AAN 2010 supports as alternative when triptans contraindicated (PMID 27432623)

Plan: Cluster headache acute attack rescue (AAN 2010 / Cohen JAMA 2009 / ICHD-3)

3. When to call your provider

Contact your care team if any of the following happen:

Refractory chronic CH (failure of verapamil + lithium + galcanezumab/topiramate) → headache specialty referral (AAN 2010 PMID 27432623)
PR >200 ms or heart block on ECG → reduce verapamil dose (AAN 2010 PMID 27432623)
Cluster mimic — attacks <30 min, very frequent → indomethacin trial (paroxysmal hemicrania pivot)
Indomethacin-responsive continuous unilateral pain → hemicrania continua (distinct entity)
SUNCT/SUNA pattern (very short <10 min, very frequent) → lamotrigine first-line, not cluster ladder
Status clusteribus (bout ≥1 mo without remission) → inpatient DHE protocol (Raskin 1986 PMID 3520384)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Chronic cluster headache — no remission ≥3 mo or remissions <3 mo within last year (ICHD-3 PMID 29368949)
Cluster bout ≥1 mo without remission, requiring aggressive bridge therapy (Raskin Neurology 1986 PMID 3520384)

5. Follow-up

Headache neurology referral if refractory; bout-end taper plan; SPG / occipital nerve stimulator candidacy for refractory chronic CH (Schoenen Cephalalgia 2013 SPG-stim Pathway CH-1 PMID 23314784)

6. Sources

Guideline: AAN 2010 Cluster Headache Practice Parameter (Robbins) + ICHD-3 + AHS 2016 + Goadsby 2025 nVNS CPG