Closing the Gaps in Cluster Headache Care: Jennifer Fokas, MD; Minali Nigam, MD

Although chronic cluster headache accounts for a relatively small share of the overall cluster headache population, it represents one of the most severe and disabling primary headache disorders.¹ A proportion of these patients experience inadequate symptom control or cannot tolerate conventional therapies, leaving clinicians with few evidence-based options. This gap is reflected in the development of CGRP-targeted therapies, such as galcanezumab (Emgality; Eli Lilly) which demonstrated efficacy for preventing episodic cluster headache but did not show benefit in chronic cluster headache.²

For acute attacks, the standard of care has remained relatively consistent, even as additional treatment options have emerged. The European Academy of Neurology guidelines give a strong recommendation for 100% oxygen delivered at a flow of at least 12 L/min over 15 minutes, as well as 6 mg subcutaneous sumatriptan, for the acute treatment of cluster headache attacks.³ In practice, clinicians typically pair these rapid, nonoral acute treatments with bridge therapies such as corticosteroids while transitioning patients to a preventive agent like verapamil.⁴ Recognizing cluster headache early, however, remains a challenge, as its features can overlap with those of migraine.

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"I think it's really important to use multiple tools. It's not just one strategy, it's figuring out what works for each individual patient."

To discuss these challenges, NeurologyLive^® spoke with Jennifer Fokas, MD, and Minali Nigam, MD, neurologists at Northwestern Medicine with specialized training in headache medicine. In the conversation, Fokas identified patients with chronic cluster headache as the population with the greatest unmet need. She also highlighted the need for a better understanding of the pathophysiology that distinguishes chronic from episodic cluster headache. Nigam added that diagnostic delays remain common, and she outlined the key clinical features that help separate cluster headache from migraine.

From there, Nigam walked through how her approach to acute attacks has evolved, emphasizing early, aggressive use of high-flow oxygen through a non-rebreather mask and the growing focus on combining oxygen with subcutaneous sumatriptan. She also described the role of intranasal triptans as second-line options and of bridge therapies, such as greater occipital nerve blocks and steroids, while preventive treatment is started. Fokas closed the conversation by stressing the importance of tailoring treatment strategies to each patient and by pointing to access to high-flow oxygen as a practical barrier the field can work to address.

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REFERENCES
1. Gimson A, Christou N, Greenwood F, Maniataki S, Goadsby PJ. An overview of the safety and efficacy of sphenopalatine ganglion stimulation for the treatment of chronic cluster headache. Expert Rev Neurother. 2026;26(7):677-686. doi:10.1080/14737175.2026.2688942
2. Chen ST, Wu JW. CGRP-Targeted Therapy for Episodic and Chronic Cluster Headache. Curr Pain Headache Rep. 2022;26(9):667-675. doi:10.1007/s11916-022-01070-6
3. May A, Evers S, Goadsby PJ, et al. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol. 2023;30(10):2955-2979. doi:10.1111/ene.15956
4. Peng KP, Burish MJ. Management of cluster headache: Treatments and their mechanisms. Cephalalgia. 2023;43(8):3331024231196808. doi:10.1177/03331024231196808