For clinicians

Cluster headache diagnosis and treatment pathway.

A quick-reference hub for busy New Zealand clinicians, built on ICHD-3 criteria and the 2023 EAN cluster headache guideline.

Awaiting clinical review · This page is awaiting completed review by a New Zealand neurologist. It is based on ICHD-3 criteria and published clinical guidelines, and is not a substitute for medical advice. How we prepare clinical content

Quick guide
Diagnosis
Treatment pathway
Oxygen access
When to refer
Reference documents

Quick guide

Acute attack in front of you

Give 100% oxygen via non-rebreather mask at 12–15 L/min (at least 12 L/min) for 15-20 minutes.
Use subcutaneous sumatriptan 6mg where appropriate and not contraindicated.
Do not rely on paracetamol, NSAIDs, codeine or oral triptans for an active attack.

Core diagnostic pattern

Severe unilateral orbital, supraorbital or temporal pain.
15-180 minutes untreated.
1 every 2 days to 8 per day during active periods.
Ipsilateral autonomic signs and/or marked restlessness.

Downloads

A one-page PDF is available for clinical use, with more detailed treatment sections below.

Download GP fact sheet PDF Patient screening summary tool

Diagnosis

ICHD-3 cluster headache criteria

At least 5 attacks.
Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes untreated.
At least one ipsilateral autonomic sign, or a sense of restlessness/agitation.
Attack frequency between 1 every other day and 8 per day.
Not better accounted for by another diagnosis.

Red flags and differential diagnosis

Consider secondary causes and urgent assessment where the presentation is atypical: first or worst headache, persistent neurological signs, systemic features, thunderclap onset, immunosuppression, malignancy history, or new onset at age under 20 or over 50. Cranial imaging is commonly recommended when the diagnosis is new or atypical.

Treatment pathway

The 2023 European Academy of Neurology guideline gives strong acute-treatment recommendations for 100% oxygen and subcutaneous sumatriptan. It identifies verapamil as the medication of choice for prevention, with corticosteroids used as transitional therapy while prevention takes effect.

Step 1

Abort attacks

100% oxygen and subcutaneous sumatriptan (strong EAN recommendations).

Step 2

Start prevention

Verapamil first-line, with ECG monitoring and dose escalation.

Step 3

Bridge

Short corticosteroid course or occipital nerve block while prevention takes effect.

Step 4

Escalate

Neurologist input: lithium, topiramate, galcanezumab or neuromodulation.

1. Abort active attacks

Oxygen: 100%, 12–15 L/min (at least 12 L/min), non-rebreather mask, 15-20 minutes.
Sumatriptan: 6mg subcutaneous injection if no contraindication.
Intranasal triptans may be slower alternatives where injections are unsuitable.

2. Start prevention

Verapamil is first-line preventive therapy.
Use ECG monitoring before treatment and with dose escalation.
Do not stop abruptly at the end of a bout; taper with clinical oversight.

3. Bridge severe periods

Short corticosteroid courses can reduce attack frequency while verapamil takes effect.
Greater occipital nerve block is a specialist option supported by the EAN guideline.
Avoid long-term corticosteroid maintenance.

4. Escalate refractory cases

Consider neurologist input for lithium, topiramate or other alternatives.
Galcanezumab has EAN support for episodic cluster headache but local funding/access must be checked.
Neuromodulation options may be relevant but access in New Zealand is limited.

Subcutaneous sumatriptan - dosing and contraindications

Dose: 6mg subcutaneous injection.
Do not repeat a second injection for the same non-responding attack - if the first injection fails, use oxygen. A second 6mg dose is only for a later, separate attack, at least 1 hour apart, to a maximum of 12mg in 24 hours.
Standard triptan cardiovascular and cerebrovascular contraindications apply (including ischaemic heart disease, uncontrolled hypertension, ergotamine and MAO inhibitors) - see the Clustran data sheet for the full list.

Oxygen access in New Zealand

Cluster headache oxygen use is different from long-term oxygen therapy for chronic respiratory disease. The clinical need is short, high-flow treatment during attacks, using the right mask and regulator.

Health NZ funds this — confirmed July 2026

In an Official Information Act response to Cluster Headache NZ dated 27 July 2026 (ref HNZ00205131), Health NZ | Te Whatu Ora stated: “Health NZ does fund intermittent high-flow oxygen for this purpose under Community Oxygen Therapy Services. It is administered through Community Services who manage the supply to people in their homes.” Health NZ confirmed in the same response that this treatment is not funded by PHARMAC.

Health NZ also confirmed that National HealthPathways lists oxygen as a treatment option for cluster headache, recommending 100% oxygen via non-rebreather mask (or a mask with an on-demand valve) at 7–15 L/min for 10–20 minutes. Some HealthPathways pages refer clinicians to POAC or local acute-demand funding if criteria are met, but CHNZ does not treat POAC, EPCC or another acute-demand scheme as the established funded home/community oxygen route unless that district confirms it.

Is a neurology referral required first? Resolved (25 August 2026). Health NZ has confirmed that a neurology referral is not a prerequisite for acute community oxygen — a GP can prescribe and administer directly. For ongoing home oxygen (recurrent bouts), the referral is to the district's respiratory service, not neurology, once the diagnosis is confirmed.

Health NZ describes access as a local clinical decision, with the district's Oxygen Specialist making the final decision under the national Community Oxygen Therapy Services specification (purchase unit DOM102). There is no national contact point. Health NZ has also confirmed that a blood gas assessment is generally not required for a patient who is not chronically hypoxaemic — it may be considered only if chronic lung disease is suspected.

Read our Official Information Act requests and Health NZ's full written responses (PDF).

In practice, funded access varies by district

The national funding basis above is confirmed, but referral does not reliably translate into supply everywhere: some districts have a clear, working pathway, others do not, and clinicians report referring patients for funded community oxygen only to have them end up arranging and paying for a private cylinder in the meantime, commonly through BOC. Consider naming the district's Oxygen Specialist directly in the referral rather than assuming a standard process. A private, self-funded supply requires no GP or specialist documentation and can be arranged in parallel while a funded referral is pursued.

Prescription wording to consider

Indication: acute treatment of cluster headache.
Gas: 100% medical oxygen.
Flow: 12–15 L/min (at least 12 L/min).
Delivery: non-rebreather mask.
Equipment: home cylinder and high-flow regulator; consider portable cylinder for attacks away from home.

The TSANZ 2024 adult home oxygen guideline makes an explicit recommendation for this indication: “Intermittent inhaled high-flow oxygen (100% at 10–15 L/min via a non-rebreather mask) can be offered to patients to treat acute cluster headache attacks and acute migraine. (Strength of recommendation: Strong; Evidence: Low).” Health NZ has pointed to Appendix 1A of its national community oxygen service specification, and to that appendix's reference to current guidance on the TSANZ website, as the basis on which cluster headache falls within the service. On that reading TSANZ 2024 is the relevant reference for eligibility as well as for safety, equipment and follow-up. Use it alongside the EAN 2023 cluster headache guideline, which covers the wider treatment picture.

On flow rate, the published figures differ: TSANZ 2024 says 10–15 L/min, NICE CG150 and EAN 2023 say at least 12 L/min, and New Zealand's National HealthPathways says 7–15 L/min for 10–20 minutes. In the only randomised comparison of flow rates (Dirkx 2018) the primary outcome was underpowered and showed no difference; more patients were pain-free at 7 L/min, while patients preferred 12 L/min. Its authors suggested starting at 7 L/min and switching to 12 if ineffective. EAN advises increasing the flow rate before concluding a patient is an oxygen non-responder, so equipment capable of reaching 15 L/min matters more than the starting figure.

When to refer

Diagnosis is uncertain or presentation is atypical.
First presentation under 20 or over 50, or any red-flag features.
Inadequate response to first-line acute and preventive treatment.
Need for higher-dose verapamil titration or ECG/medication complexity.
Suspected chronic cluster headache.
Contraindications to oxygen, sumatriptan or verapamil pathways.
For funded home oxygen: refer to your district's community oxygen service for decision by that district's Oxygen Specialist. Health NZ has confirmed no neurology referral is required to start acute treatment; ongoing home oxygen is referred to respiratory services once diagnosis is confirmed.
Consideration of nerve blocks, lithium, topiramate, CGRP therapies or neuromodulation.

Clinical feedback welcome

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If you are a clinician and see anything that should be corrected, clarified or localised for New Zealand practice, please contact us. Corrections from clinicians are applied carefully.