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