# Cluster headache (acute attack & prophylaxis) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: NICE Guideline CG150 · Egyptian National Drug Formulary - Nervous System Disorders 2025 · Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) · Sumatriptan 6 mg/0.5 mL solution for injection SmPC sections 4.2-4.3 (eMC product 607) · Cluster Headache - StatPearls - NCBI Bookshelf (NBK544241) - the disease article carries both the indication and this dose - Verified date: 2026-08 ## Verified against - Sumatriptan 6 mg/0.5 mL solution for injection SmPC sections 4.2-4.3 (eMC product 607) - NICE Guideline CG150 - Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) - Cluster Headache - disease-level clinical article (cluster-headache-full.txt) ## Treatment metadata - Sumatriptan — 6 mg — injection - Oxygen — nasal - Verapamil — 80 mg — oral.solid - Referral & safety-netting (no drug therapy) - Prednisone — 5 mg — oral.solid ## Complete treatment card ```text CLUSTER HEADACHE (ACUTE ATTACK & PROPHYLAXIS) Sources: NICE Guideline CG150 · Egyptian National Drug Formulary - Nervous System Disorders 2025 · Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) · Sumatriptan 6 mg/0.5 mL solution for injection SmPC sections 4.2-4.3 (eMC product 607) · Cluster Headache - StatPearls - NCBI Bookshelf (NBK544241) - the disease article carries both the indication and this dose Review status: REVIEWED against Sumatriptan 6 mg/0.5 mL solution for injection SmPC sections 4.2-4.3 (eMC product 607), NICE Guideline CG150, Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph), Cluster Headache - disease-level clinical article (cluster-headache- full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (7) - Attacks cause severe, sudden one-sided pain around or above the eye, rated ten out of ten - Light and sound sensitivity, when present, tend to affect only the painful side, unlike the bilateral pattern seen in migraine - Attacks last 15 minutes to 3 hours and can recur up to eight times a day, most often at night - Up to a third of patients develop general skin sensitivity, more common in women and those with recent attacks or comorbid depression [low mood] - Suicidal thoughts can accompany attacks, though completed suicide is rare [suicidal thoughts] - Bouts over weeks to months alternate with remissions of months to years; a full year without remission defines the chronic form - Alcohol, hot weather, stress, nitroglycerin, sexual activity, and glare are described as possible triggers SIGNS - what you find (5) - Eye redness or tearing on the same side as the pain occurs in about 90% of attacks [eye discharge · eye redness] - A blocked or runny nose on the affected side is seen in roughly 84% of attacks [blocked nose · runny nose] - Eyelid or facial swelling occurs in about 59% of attacks [eyelid swelling · facial swelling] - A constricted pupil or drooping eyelid can appear on the side of the headache [headache · ptosis · small pupil] - Patients are agitated and restless during attacks, pacing or rocking rather than lying still as migraine sufferers do [irritability] TESTS (3) - A questionnaire on attack duration under 180 minutes plus autonomic features has about 81% sensitivity and 100% specificity - Formal diagnosis requires at least five qualifying attacks - MRI, or contrast CT as an alternative, is used to exclude a structural or pituitary cause such as a prolactin-secreting tumor IF NOT THIS - what else fits (7) - Paroxysmal hemicrania lasts only 2 to 30 minutes and responds to indomethacin - SUNCT lasts only 5 to 240 seconds, can recur up to 200 times a day, and usually resists treatment - Tension headache is bilateral, a dull or squeezing ache linked to fatigue and tender pericranial muscles - Trigeminal neuralgia is a brief electrical or stabbing pain in the trigeminal distribution lasting only seconds - Primary stabbing headache causes brief stabs of 1 to 10 seconds without autonomic features - Migraine is typically a one-sided throbbing headache with the patient lying still in a dark room, and up to half of patients also have bilateral autonomic symptoms, making it the condition most often confused with cluster headache - Structural lesions such as carotid artery dissection, intracranial aneurysm, a pituitary tumor, or nasopharyngeal carcinoma can also mimic these headache attacks Source StatPearls "Cluster Headache" - disease-level clinical article Status traced to the source above Rx: Acute attack | Prevention | Main treatment | Transitional prevention - covers the weeks before verapamil works ACUTE ATTACK - choose one 1. SUMATRIPTAN [1st line] Adult 6 mg subcutaneously at onset of attack; max 12 mg in 24 hours (minimum 1 hour between doses) - acute attack Peds Not recommended in children under 18 years for cluster headache Choice Alternatives for aborting the attack. High-flow oxygen is co-equal on the evidence and the entry keeps it, but no oxygen product appears in the Egyptian register, so it cannot be what a prescription names. Source Sumatriptan 6 mg/0.5 mL solution for injection SmPC sections 4.2-4.3 (eMC product 607) Why Triptan (serotonin receptor agonist) used to abort an acute cluster headache attack by constricting cranial blood vessels and inhibiting release of vasoactive neuropeptides. Caution Contraindicated in ischemic heart disease, previous MI, or uncontrolled hypertension. Do not use within 24 hours of ergotamine derivatives. Transient chest tightness or tingling sensations may occur. If the first injection does not touch the attack, a second will not either - do not repeat within the same attack. The second 6 mg is for the next attack, an hour or more later. Barred by ischaemic heart disease, a previous infarct, Prinzmetal's angina, any stroke or TIA, and moderate or severe hypertension - or mild hypertension that is not controlled. Never with ergotamine, another triptan, or an MAOI. Egypt SUMIGRAN 6MG/0.5 ML PREFILLED SYRINGE SIGMA TEC 30.00 EGP SUMAGRAINE 6MG AMP. UP PHARMA 40.00 EGP 2. OXYGEN [1st line] Adult 100% Oxygen at 12-15 L/min via non-rebreather mask with reservoir bag for 15-20 minutes - acute attack Peds Specialist pediatric neurology guidance required Source NICE Guideline CG150 Why First-line acute abortive therapy co-equal with triptans; essential primary option when triptans are contraindicated or unavailable. Caution Must be delivered via high-flow non-rebreather mask with reservoir bag at 12-15 L/min (standard nasal cannula or low-flow concentrators <=5 L/min are ineffective). Caution in severe COPD or hypercapnic respiratory failure. In Egyptian primary care, high-flow oxygen is available in clinic/ER settings for acute attacks; for home use, patients require high-flow cylinder setups as standard home oxygen concentrators (5 L/min) are insufficient. Egypt no Egyptian brand matched - prescribe by generic name PREVENTION 3. VERAPAMIL [1st line] Adult 80 mg 3 times daily, titrate by 80 mg every 3-14 days up to 240-480 mg daily in divided doses - prophylaxis (during cluster bout) Peds Not indicated for cluster headache prophylaxis in children Source Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) Why Calcium channel blocker used for cluster headache prevention rather than for aborting an attack already under way; it is the standard preventive choice, taken through a cluster period to reduce how often attacks occur. Caution A baseline ECG is required before starting and with each dose increase (risk of heart block and bradycardia). Contraindicated in second/third-degree AV block, severe bradycardia, or heart failure. Constipation and peripheral edema are common. Egypt VERPAMIL 80MG 20 F.C.TAB. EL NASR 7.00 EGP (0.35/unit) VERATENS 80MG 10 F.C. TAB. PHAROPHARMA 4.75 EGP (0.47/unit) IZOPTOMIL 80 MG 20 TAB. ARAB DRUG COM... 10.00 EGP (0.50/unit) ISOPTIN 80 MG 30 F.C. TABS. KAHIRA > ABBO... 50.00 EGP (1.67/unit) MAIN TREATMENT 4. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Cluster Headache - disease-level clinical article (cluster-headache-full.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Neuroimaging (MRI or CT with contrast) is needed to rule out structural and pituitary lesions. TRANSITIONAL PREVENTION - COVERS THE WEEKS BEFORE VERAPAMIL WORKS - give alongside 5. PREDNISONE [add-on - not a substitute] Adult 60 to 100 mg once a day for at least five days, then step the dose down by 10 mg each day until it is stopped. - At least five days at the full dose, then a taper of 10 mg a day - a short course only Peds No paediatric dose in the sources opened - cluster headache in a child belongs with a neurologist. Source Cluster Headache - StatPearls - NCBI Bookshelf (NBK544241) - the disease article carries both the indication and this dose Why Verapamil takes weeks to work, and the article recommends a steroid to cover that gap during a short cluster period. It is a bridge, not a long-term preventive, and it is the one thing that shortens a bout while the real preventive is being titrated. Caution This is a short bridging course only; the article warns that steroids are not prescribed for an extended period because of their long-term harms. It raises blood sugar and blood pressure and holds on to salt and water - check both, and take care in a diabetic or hypertensive patient. It masks and worsens infection, and can reactivate a latent one such as tuberculosis. Mood swings, insomnia and, rarely, psychosis can appear at these doses; warn the patient and the family. The only Egyptian prednisone tablet is 5 mg, so a 60 mg dose means twelve tablets - check the patient can actually take the course before prescribing it. Egypt HOSTACORTIN 5MG 30 TAB. SANOFI AVENTI... 12.00 EGP (0.40/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)