Cluster Headache Prevention

Cluster headache prevention is the key to managing cluster headaches in the long-term.

Avoid Triggers

There is a statistical association between patients with cluster headaches and both smoking and caffeine use. While an unproven intervention, I generally recommend that patients avoid both.

Alcohol is a clear cluster headache trigger and should certainly be avoided during a cluster bout.

Obstructive sleep apnea (OSA), which refers to long pauses in breathing while a person is asleep, may be a cluster headache trigger. Many patients may not know they are suffering from obstructive sleep apnea. Clues to this diagnosis include feeling excessively sleepy during the day, being overweight or with a large circumference neck compared to its length, and being observed by others to have significant snoring or even observed long pauses in breathing while sleeping (apnea). Obstructive sleep apea has many treatments, among them are weight loss and use of a special breathing device to be worn while sleeping (CPAP). Patients with known OSA should use CPAP to avoid triggering cluster headaches.

Transitional Therapy

In order to alleviate pain, most headache specialists will start a cluster headache patient on special medications to be used in the short-term (over a few weeks) while the patient is transitioned to longer-term therapy. This is essentially short-term cluster headache prevention. Examples of what can be used for this purpose follow:

Prednisone

Prednisone is an oral steroid medication (a powerful anti-inflammatory medication) which can dramatically and quickly reduce the number of headaches a patient is experiencing. Dosing and duration of therapy vary, but one approach is to start patients on 100mg a day, with a reduction in dose by 10mg each day until the coarse is completed. Other oral steriods used for this purpose include prednisolone or dexamethasone.

Ergotamine

Ergotamine is a vasoconstricting medication which can markedly reduce cluster headache attacks. The medication can be taken orally (2 to 4mg per day) as a preventative between 1 to 4 weeks. For patients with headache attacks that mainly occur while they are sleeping, the medication can be taken at bedtime to maximize effectiveness. Other options include a rectal suppository (2mg ergotamine and 100mg of caffeine) or injections into the muscle of 0.5mg ergotamine at bedtime.

Methysergide

This is a vasocontrictive medication which has been discontinued in the United States but is available in Europe. It is effective between 3 and 12mg per day. It has the advantage of working both as a transitional therapy and a potential longer-term preventative. It is generally not used with other vasoconstrictive medications like ergotamine, DHE, or triptan medications.

Dihydroergotamine (DHE)

Injections into the vein (IV) of another vasoconstrictor medication, dihydroergotamine (DHE), seems to be very effective for patients who are in considerable distress and for whom other transitional therapies are not working. A person can be admitted to the hospital and undergo frequent (every 8 hours) injections of DHE for about three days while other longer-term preventative therapies are being started.

Triptan Medications

Longer-acting oral medications, often used to treat migraine headaches, may also be effective as transitional therapies. Promising options include Amerge (naratriptan), Frova (frovatriptan), or Relpax (eletriptan). The medications are administered two times a day for a few weeks as prevention – while another longer-term therapy is being started.

Occipital nerve blocks

The greater occipital nerve (GON) supplies sensation for much of the scalp. Each GON runs from the back of the head up to the forehead region on one side. Steroid injections (given at the base of the GON, at the back of the head) on the side of the cluster attacks appear to reduce or sometimes stop cluster headache attacks. In our office, a local anesthetic (lidocaine) is mixed with the steroid.

Long-term Prevention

Either simultaneous with or soon after starting one of the transitional treatments above, I like to start cluster headache patients on long-term prevention. The choice of drug for cluster headache prevention depends on many factors. Past efficacy is very important. If a patient already knows he/she responds well to a medication, I will likely use that medication again. If a person has never been on a longer-term preventative, then I’ll usually use something which has a reputation for being effective but that has a low risk of serious side effects.

Verapamil

Verapamil is a calcium channel blocker which is often used for blood pressure or heart rate control. It can be a very effective cluster headache prevention medication and is usually my first choice unless a patient has tried it unsuccessfully in the past.

The dose must be slowly increased over time. I will often start patients on a long-acting form of the medication (Calan SR 120mg or Veralan PM 100mg) and slowly increase the dose over time, as tolerated and as needed for headache prevention. I usually have patients return to the office for an EKG once they reach 200-240mg to look for any early evidence of cardiac conduction problems (heart block). Sometimes very high doses of the medication are needed to prevent headaches (960mg a day) and the dose titration must be performed carefully to avoid cardiac problems or too low of a blood pressure. Common side effects with this medication include constipation and swelling in the legs.

Valproic acid (Depacon, Depakene) or divalproex sodium (Depakote)

These medications are commonly used to treat seizures but in many cases will also work for cluster headache prevention. Doses are started low and gradually increased over time until headaches subside or side effects prevent further increases. I typically use Depakote ER (a long-acting form of the medication that can be taken once a day) starting with 500mg a day and increasing by 500mg each week – going as high as 2000mg per day if needed. This is a fairly rapid increase in dosing but if a patient is experiencing significant pain, they won’t mind as much the greater chance of side effects with these rapid increases. Common side effects include sedation, feeling off balance, tremor, rash, hair loss, or problems with irritation of the liver, or sometimes blood abnormalities. For the later two reasons, I will frequently monitor blood work to look for evidence of blood cell abnormalities, liver function test abnormalities, and to monitor the level of valproic acid in the blood.

Lithium

Lithium is commonly used to treat bipolar (manic depressive) disorder. I rarely use this medication for cluster headache prevention since other, safer, options are typically helpful. Worrisome side effects include seizures, tremors, confusion, thyroid disorders and kidney disorders (diabetes insipidus). The medication can be started at 300mg twice a day and gradually increased to as high as 1200mg total daily dose. Blood levels must be monitored frequently to prevent too high a level (and thus toxicity) from occurring. (Effective blood concentrations for headache prevention are around 0.4-0.8 mEq/liter.)

Methysergide

As noted above, is an oral vasocontrictive medication which has been discontinued in the United States but is available in Europe. It is effective between 3 and 12mg per day. It has the advantage of working both as a transitional therapy and as a long-term preventative. When used for cluster headache prevention it is generally not used with other vasoconstrictive medications like ergotamine, DHE, or triptan medications.

Topamax

Topamax, a medication commonly used to prevent seizures and migraine headaches, may also be helpful in cluster headache prevention. So far, limited supportive evidence is available. Doses range from 25mg per day to as high as 250mg per day (once a day).

Gabapentin (Neurontin)

This medication is commonly used to prevent seizures and to treat painful conditions, such as pain due to nerve irritation or migraine headaches. There is at least one study that supports its use in preventing cluster headaches. The medication can be taken at bedtime, starting at 300mg and increasing as tolerated up to 900mg at bedtime. Typical side effects include sleepiness, feeling off-balance, poor concentration, and ankel swelling.

Other options

The following options are not commonly used for cluster headache prevention but should be mentioned at least briefly:

Melatonin supplements may help in cluster headache prevention.

Leuprolide (a synthetic hormone) injected into the muscle (once only) may reduce cluster headaches.

For patients who responded briefly to occipital nerve blocks (see above) and who are suffering from chronic cluster headaches (having no significant reprieve from their headaches) a stimulator can be implanted over the occipital nerve for low-intensity stimulation. This probably works to ‘block’ occipital nerve pain transmission and may reduce cluster headache attack frequency and intensity.

There have been good experimental results with implantation (into the brain) of hypothalamic stimulators. Clearly all other options would need to be explored before considering this approach.

What do I do when my cluster cycle has ended?

For patients with episode cluster headaches (headaches that last a few weeks or a month and then end for at least a year), no matter what the treatment, the headaches at some point will stop. While this is great, you may still want to know whether you should continue with your cluster headache prevention medications. Clearly this must be discussed with your treating physician. I advise patients to make sure they are ‘out of danger’ for recurrence by waiting at least an extra week beyond the usual duration of their cluster cycles (or bouts). They can then begin to slowly taper off the medication they are using for long-term prevention. At any point, if the headaches begin to recur, then the dose should generally be increased again until headaches have again abated.

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