“The second significant advance was the approval of galcanezumab, an anti-calcitonin gene-related peptide (CGRP) monoclonal antibody, for the prevention of episodic cluster headache,” Dr Tepper told Neurology Times.
During nitroglycerin-triggered and spontaneous cluster attacks, plasma concentrations of CGRP may be increased.1 In addition, evidence has linked elevated CGRP levels with the initiation of some cluster episodes.1 Galcanezumab has demonstrated efficacy in decreasing the amount of weekly cluster attacks in patients with episodic cluster headache, according to results from a randomized study.1,5 The once-monthly injectable recently became the first therapy to be approved by the FDA for the treatment of episodic cluster headache in adult patients.6
“These both represent very significant advances in the treatment of cluster headache. The first approved treatment for cluster headache in the US, the sumatriptan injection, [occurred] almost 20 years ago,” he explained.
While several novel therapies have emerged, triptans and oxygen are still the mainstay of acute cluster headache management.1 In particular, high-flow oxygen using a non-rebreather mask, intranasal zolmitriptan or sumatriptan, in addition to subcutaneous sumatriptan have all shown particular efficacy in the acute treatment setting.1
With respect to preventive treatment, evidence-based therapies include verapamil, lithium, topiramate, and melatonin. Verapamil is typically administered as first-line preventive treatment but is often limited by dose-dependent cardiac arrhythmias. Ultimately, the goal is to wean patients off prophylactic therapy at the end of a cluster bout.1
“We [now] have a neuromodulation device approved as adjunctive preventive treatment for both episodic and chronic cluster, [which is] also approved for acute treatment of episodic cluster, and a biologic approved for prevention of episodic cluster,” Dr Tepper concluded.
Effective management of cluster headache can be challenging for busy clinicians, largely because of the varying clinical presentation and numerous treatment strategies. Ultimately, improving patient quality of life and reducing cluster attack burden remain key goals of therapy.
1. Wei DY, Khalil M, Goadsby PJ. Managing cluster headache. Pract Neurol. 2019 Jul [Epub ahead of print].
2. Goadsby PJ, de Coo IF, Silver N, et al. Non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: a randomized, double-blind, sham-controlled ACT2 study. Cephalalgia. 2018;38:959-969.
3. Gaul C, Diener HC, Silver N, et al. Non-invasive vagus nerve stimulation for PREVention and Acute treatment of chronic cluster headache (PREVA): a randomised controlled study. Cephalalgia. 2016;36:534-546.
4. Schoenen J, Jensen RH, Lantéri-Minet M, et al. Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. pathway CH-1: a randomized, sham-controlled study. Cephalalgia. 2013;33:816-830.
5. Bardos JN, Goadsby PJ, Dodick D, et al. A placebo-controlled study of galcanezumab in patients with episodic cluster headache: results from the 8-week double-blind treatment phase. Presented at: 2019 American Academy of Neurology Annual Meeting. May 4-10, 2019; Philadelphia, PA.
6. FDA approves first treatment for episodic cluster headache that reduces the frequency of attacks [press release]. Silver Spring, MD: FDA. Published June 4, 2019. http://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-episodic-cluster-headache-reduces-frequency-attacks. Accessed June 29, 2019.