What are the recommended treatments for preventing cluster headaches?

Recommended Treatments for Preventing Cluster Headaches

For the prevention of cluster headaches, galcanezumab is recommended as first-line treatment for episodic cluster headache, while verapamil remains a widely used option despite insufficient evidence according to recent guidelines. 1, 2

First-Line Preventive Treatments

Episodic Cluster Headache Prevention

• Galcanezumab is recommended as first-line prophylactic treatment for episodic cluster headache with the strongest evidence among available options 1, 2
• The 2023 VA/DoD guidelines provide a weak recommendation for galcanezumab specifically for episodic (not chronic) cluster headache 1
• Verapamil (at least 240 mg daily, with maximum dose depending on efficacy and tolerability) is commonly used, though recent VA/DoD guidelines note insufficient evidence to recommend for or against it 1, 3, 4
• Corticosteroids (at least 100 mg prednisone or equivalent) are effective for short-term prevention or as bridging therapy 3, 5

Chronic Cluster Headache Prevention

• Galcanezumab is specifically not recommended for chronic cluster headache prevention (weak recommendation against) 1
• There is insufficient evidence to recommend for or against verapamil for chronic cluster headache prevention 1
• Alternative preventive options include lithium and topiramate when first-line treatments are ineffective or contraindicated 3, 5, 4

Acute Treatment Options (for reference)

• Subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) are recommended for acute treatment of cluster headache attacks 1, 3
• Normobaric oxygen therapy (100% oxygen at flow rates of at least 12 L/min for 15 minutes) is recommended for acute treatment 1, 2, 3
• Noninvasive vagus nerve stimulation is suggested for the short-term treatment of episodic cluster headache 1

Important Considerations and Monitoring

Verapamil Considerations

• Despite its widespread use, high-dose verapamil requires careful cardiac monitoring due to potential adverse events 6
• Cardiac adverse events reported with high-dose verapamil include bradycardia, AV blocks, syncope, and sick sinus syndrome 6
• ECG monitoring is essential when using verapamil at doses exceeding 240 mg daily 6, 4

Other Preventive Options

• Melatonin may be effective for some patients with cluster headache 5, 7
• Greater occipital nerve blocks may be beneficial as a transitional treatment 3, 7
• Implantable sphenopalatine ganglion stimulator is not recommended for cluster headache treatment (weak recommendation against) 1

Treatment Algorithm

1. First-line for episodic cluster headache: Galcanezumab 1, 2
2. Alternative options: Verapamil (with cardiac monitoring), lithium, topiramate 3, 5, 4
3. Short-term/bridging therapy: Corticosteroids (prednisone 100 mg or equivalent) 3, 5
4. For acute attacks: Oxygen therapy and/or subcutaneous sumatriptan/intranasal zolmitriptan 1, 3