When to Take Your Abortive Treatment for Cluster Headache Attacks

Cluster headaches are an enigma. On the one hand, they're predictable that they will wake you from sleep and happen around the same hours (sometimes to the minute) every day. On the other hand, an episodic cycle can blindside you if you've been pain-free for months (or years!). Even chronic patients experience high cycles where attacks are more frequent. It can be hard to tell a "shadow" from an attack during these times. You might question if you need to grab your home oxygen, injection, nasal spray, or whatever is in your abortive arsenal for treatment.

A "shadow" versus cluster headache attack

A "shadow" is similar in some ways to the migraine aura that comes before a migraine attack. It's not so much visual or auditory but described as a twinge. That twinge can start in your neck, temple, or behind your eye. The sensation will either burrow deeper into your brain, becoming a full cluster headache attack or dissipate within a few minutes. Those minutes can seem eternal, though.

It's imperative to use abortive treatments for cluster headaches immediately because of the sudden onset of attacks. You usually don't have time to sit around and wait, but you also don't want to waste valuable medication or oxygen tanks if it's a devious shadow. When you're limited to a handful of injections each month by insurance or pay out of pocket for home oxygen, telling the difference between a shadow and the real start of a cluster headache is crucial.

I don't have a set way to tell the difference, but if the twinge grows into a knife that's stabbing further behind my eye and temple, I quickly grab my closest abortive. But, if the feeling comes and goes or I can concentrate on something else, I hold off. That typically happens within 3-5 minutes of the initial shadow pain.

Energy drinks as a treatment

One of the tricks of treating cluster headaches involves energy drinks or energy shots containing caffeine and taurine. We don't know why it works but chugging a Red Bull or downing a 5-Hour energy shot can prevent an attack from jumping to 10/10 pain or stop it in its tracks. The window for this energy drink hack is tiny—under five minutes in my experience.

Home oxygen therapy

100% oxygen through a non-rebreather mask at 12-15 liters per minute (lpm) is the most effective way to stop a cluster headache attack. What's frustrating is that getting oxygen for cluster headaches is often the biggest struggle facing patients. It took me 7 years to get oxygen, but I still regularly have issues with oxygen suppliers. If you have oxygen tanks, you'll want to reach for your mask as soon as possible. Most people with cluster headaches can stop an attack within 15 minutes with home oxygen. For me, it's about 9 minutes.

Injections for cluster headaches

Sumatriptan injections are also useful in ending attacks quickly—About 4.5 minutes for me. Insurance limits me to 9 sumatriptan vials a month that I can stretch to stop about 27 attacks by using just 2-3mg each time. With 4 cluster headaches a day, the vials still run dry fast. Others may have the auto-injectors that come pre-filled, which insurance can limit to as few as 4 a month. These injections can work wonders, but they come at an additional cost: "Rebound attacks," as we often call them. My daily attacks go up to 6 when I use sumatriptan. While they're great in a pinch, they mean I'll face more pain later.

DHE injections are sometimes used for cluster headaches too. Medical professionals don't recommend them as much as they used to, though. Injectable medications are ideal for cluster headaches because they work quickly to treat the sudden nature of attacks.

Nasal sprays

Nasal sprays such as zolmitriptan or ketamine are the next best thing. In studies, zolmitriptan in nasal form could abort a cluster headache attack in about 20 minutes. Ketamine nasal spray may work faster than that but is still a newer option for patients, which means we have limited data on its efficacy. It seems to work very well for patients who don't respond to other treatments. DHE also comes in a nasal spray, which works for some.

Treat your cluster headache attack ASAP

While differentiating between an attack and a shadow that may or may not progress into an attack can be difficult, you need to treat it within 5-10 minutes to get relief. If I wait more than ten minutes to do an injection, it may not work for the pain at all. The same goes for oxygen. The longer you wait to grab your oxygen mask, injection, or nasal spray, the more time it will take to end the pain. You also run the risk of treatment not working at all when you wait too long.

The treatment window is small for cluster headaches. You will get to know your attack pattern as the cycle goes on, making it easier to tell the precise moment you need your abortive treatment.