Prevention of Cluster Headache Attacks

Methods of preventing a Cluster Headache Attack

Occipital nerve block

Injecting an anesthetic and steroids near the occipital nerve on the side of the cluster attacks is a short term prevention that is used at times while other preventatives are being attempted.  It reduced the number of cluster headaches quickly but the benefit is short lived.  Because a steroid is used, it cannot be repeated very many times.

Emgality®

Emgality is the only drug FDA approved for the prevention of cluster.  It was only demonstrated to work for preventing cluster headache in those patients with episodic cluster headache.  It did not work in chronic cluster headache.  It takes about 2 weeks to begin to get a meaningful response.  It does not work for all patients and it does not work to prevent all headaches so Dr. Loftus typically combines this with other treatments.  It is usually covered by insurance as long as one prior preventative has been attempted.

Sphenopalatine ganglia block (SPG block)

SPG block is now possible using a device that is placed by a physician througth the nose. One of these devices is Allevio™. With this device, lidocaine, a local anethetic is used to produce the block. It also blocks the 2nd branch of the trigeminal nerve. This treatment not only treats an acute headache but appears to help prevent future headaches. There is limited controlled data at this time. Most insurances will pay for this therapy at this time. This therapy can safely be done during pregnancy. Bellaire Neurology currently offers this therapy to patients.

Steroids

Once an attack of cluster headaches has begun, the traditional treatment used to prevent future cluster headaches in the series is steroids. Prednisone is commonly used at doses up to 100 mg a day. Steroids have many potential side effects so many physicians have begun to use it as a second-line agent. If a patient is in the middle of a severe cluster attack in which they feel they have reached their limit, then using prednisone while starting an additional first line agents is reasonable.

Zonisamide

Dr. Loftus published the largest case series of using zonisamide for cluster headache prevention.  In this case series, it demonstrated benefit in both episodic cluster and chronic cluster patients.  Since it was open label, this treatment is not considered proven but can still easily be tried.  Combined with verapamil, it is one of Dr. Loftus’ first line treatments.  It does have a 1-2% chance of causing renal stones.  For this reason, some patients would rather avoid this medication.  Zonisamide has about a 20% cross reaction allergy to those allergic to sulfa based antibiotics.

Verapamil

The most common first-line agent for cluster prevention is relatively side effect free and is called verapamil. Verapamil is generic and made by many different drug manufacturers. It is available in a long acting, short acting as well as other forms. The most common side effects of verapamil are ankle swelling and constipation. Patients with known cardiac conduction defects should also not take verapamil.  It is one of the most widely used cluster preventatives because it is relatively side effect free.

Topiramate

Topiramate is FDA approved for migraines but has been used for cluster headache prevention.  Unfortunately, the typical dose needed to treat cluster is quite high.  At the higher doses, topiramate is more likely than zonisamide to cause cognitive side effects with word finding difficulty being the most common.  For this reason, Dr. Loftus typically uses zonisamide before topiramate.  The exception are those patients with a sulfa drug allergy.

Divalproex

Divalprox is sometimes used to prevent cluster headaches but requires liver function monitoring and is commonly associated with weight gain.  It is available by IV so it can be started quickly.

Lithium

Lithium is sometimes used to prevent cluster headaches but has a relatively narrow therapeutic index.  A narrow therapeutic index means it is more difficult to use the drug because the difference in the dose needed to treat the patient and the dose where the drug causes toxicity is small.  For this reason, Dr. Loftus tends to put it down the list of medication that he uses and patients started on this drug typically need blood work one week after each dose change.

Methergine

Methergine is a potentially dangerous drug with the possibility of causing retroperitoneal fibrosis and cardiac valve issues.  On the other hand, it does work like an oral dose of dihydroergotamine.  The issue now is the cost is so high that getting insurance to cover it is very difficult.

SPG Stimulation

Approved in Europe, SPG stimulation by a device made by Autonomic Technologies appears to potentially treat the painful attack along with preventing future attacks. {Stimulation of the sphenopalatine ganglion for cluster headache treatment. US studies are in progress at the time of this writing (August 2014). {Pathway CH-1: A randomized, sham-controlled stuy. Schoenen J, et.al. Cephalgia 33(10) 816-30}

Additional Methods of Preventing a Cluster Headache Attack

When the above medications do not work, other CGRP related migraine preventatives can be attempted.