Cluster headache primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sabeeh Islam, MBBS[2]

Overview

The drug of choice for primary prevention of cluster headache is Verapamil. Other agents that can be used also include glucocorticoids, topiramate and lithium.

Primary Prevention

Verapamil:

• Mostly used for episodic and chronic cluster headache
• Usually starts with a dose of 240 mg and can be titrated upto 480 mg to 960 mg , depending upon the tolerance Dose is usually increased by 80mg every 10-14 days
• An EKG is recommended before starting the treatment as Verapamil can cause EKG changes such as heart block and bradycardia, with a total daily dose of 480mg.
• Side effects include: edema, gastrointestinal discomfort, constipation, dull headache, and gingival hyperplasia

Glucocorticoids:

• Several open label studies have shown that glucocorticoids have reduced the frequency of cluster headaches
• Prednisone 30 mg daily or a higher dose can be used
• Dexamethasone 8 mg daily in two divided doses

Topiramate:

• Topiramate is generally used as an add on therapy or combination therapy with Verapamil to prevent high dose use of verapamil and long term glucocorticoid therapy.

Lithium:

• Lithium is generally used for chronic cluster headaches when the first line agents are ineffective.
• There is very limited data about the efficacy and effectiveness of lithium.

Galcanezumab:

• Galcanezumab is generally used for prevention of episodic cluster headaches.
• Dose: 300 mg at the onset of cluster headache and later on once every month.

Greater occipital nerve blocks:

• Refractory chronic cluster headaches sometimes respond temporarily to local glucocorticoid injection or greater occipital nerve block.

Others:

• Pizotifen
• Valproate
• Capsaicin
• Triptans
• Ergotamine
• Melatonin
• Indomethacin
  

References

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