Transitional therapy is a short-term preventive treatment that bridges the time between cluster diagnosis and when a true preventive agent becomes effective. Transitional preventives are started at the same time the true preventive is begun (see below). The transitional preventive should provide the cluster patient with almost immediate pain relief and allow the patient to be headache-free or near headache-free while the maintenance preventive medication is being tapered up to an effective level. When the transitional agent is tapered off (typically in one to two weeks) the maintenance preventive will have kicked in, thus the patient will have no gap in headache prevention.
Steroids (e.g., prednisone, dexamethasone)
- The best transitional therapy for cluster
- Typically effective within 24 to 48 hours of administration
- Usually discontinued after 8-10 days of treatment when main preventive agent has started to become effective
- Long-term use not recommended because of very severe side effects with extended usage
- Patient must be screened because steroids pose a risk for some patients, even when used for a short period of time
Dihydroergotamine (DHE)
- Can be used as either abortive or transitional therapy
- Best given intravenously in a hospital or outpatient infusion setting
- Typically relieves pain in 1-2 days of repetitive treatment; pain may not return for days to months which allows time for a preventive(s) to become effective
Naratriptan
- Dose — 7 days at 2.5 mg twice daily while transitioning to a preventive program
- Drawback — if an attack occurs when a cluster patient is on naratriptan, sumatriptan cannot be used as an abortive; however, oxygen therapy can be used in this case
Occipital nerve blockade
- Injection of anesthetic agent and a small dose of steroid into the region of the greater occipital nerve (base of skull) can provide relief averaging 13 days
- Can be performed in an outpatient setting with minimal discomfort for the patient
- Comparable to getting Novocain at the dentist
- More studies are necessary to establish this as a legitimate transitional treatment for cluster headache
