The main goal of cluster headache preventive therapy is to make a patient cluster-free on preventives even though they are still in a cluster cycle. Preventive agents are absolutely necessary in cluster headache. The maintenance preventive should be started at the time a transitional agent is given. Sometimes very large dosages, much higher than that suggested in the literature, are necessary when treating cluster headache. It is not uncommon for cluster patients to require several preventive medications at once to get better results. Most physicians treating cluster will increase the dosages of the preventive agents very quickly to get a desired response.
Preventive medications are only used while the patient is in cycle and then are tapered off once a cluster period has ended. If a patient decides to remain on a preventive agent even after their cluster cycle has ended, it does not appear to prevent a subsequent cluster period from starting.
Verapamil
- May be the best first-line preventive therapy for both episodic and chronic cluster
- Can be used in conjunction with sumatriptan, ergotamine, corticosteroids, and other preventive agents
- Sustained-release formulation does not work as well as the normal release drugs at the same dose
- An electrocardiogram (EKG) is necessary before each dose change thereafter periodically to guard against a rhythm disturbance caused by the drug
Topiramate
- Newer anti-seizure medication that appears to be effective in both migraine and cluster headache
- Effective for both episodic and chronic cluster sufferers
- Topiramate in fairly low dosages can turn off cluster headaches on average within 1-2 weeks after starting the medication
Lithium carbonate
- Effective but narrow therapeutic window and high side effect profile make it less desirable than newer preventives
- Effective in both episodic and chronic cluster headaches
- Serum lithium concentrations should be checked during initial treatment stages to guard against toxicity; renal and thyroid functions need to be checked prior to starting lithium
Methergine
- It has a role in the prevention of cluster headache and acts as an ergot preparation
- MHNI physicians generally take people off Methergine after 3-6 months
- If prolonged therapy is necessary, then special testing is required because of possible long-term risks with the drug
Valproic acid
- Similar efficacy in both episodic and chronic cluster treatment
- May be more effective in patients whose cluster headaches are accompanied by migraine-type features, such as nausea, vomiting, photophobia, and phonophobia
Naratriptan/Frovatriptan *
- Remains effective in the body for a longer period of time than other available triptans
- Drawback — if breakthrough attack occurs, sumatriptan (another triptan) cannot be used as abortive; however, oxygen therapy can be used in this case
- Caution is urged when using a daily triptan in a patient who smokes
* Generally we do not recommend a triptan for daily use, but in some cases long-acting naratriptan or Frovatriptan can be used
Melatonin
- Natural sleep hormone that is produced in less than normal amounts by cluster patients. This may be an inciting factor in cluster headaches that occur in the night
- Can be used along with other cluster medications; may be able to use a lower dose of other medications when used with melatonin
- Trials have shown that fairly large doses can stop cluster attacks. Suggested dose is 6 to 9 mg at bedtime
- Purchased over-the-counter and appears to have minimal side effects. No current governmental regulation; therefore, if one brand does not help, trying another brand of melatonin may be worthwhile
- Should consult physician before starting
Baclofen
- Baclofen, also known as Lioresal, can be used as an excellent preventive drug for some individuals
- It is quite safe when started at a low dose and built upward
- The drug should be reduced slowly at the time of discontinuation
Other possible preventives
A small number of case reports suggest the use of transdermal clonidine, tizanidine, and Thorazine for cluster prevention. These preventives should only be tried when other well-recognized preventives have failed and if there is no contraindication for their use.
