What is the prophylactic treatment for cluster headaches?

Prophylactic Treatment for Cluster Headaches

First-Line Prophylaxis Based on Cluster Type

For episodic cluster headache, galcanezumab is the first-line prophylactic treatment with the strongest evidence among available options, while verapamil remains the drug of choice for chronic cluster headache despite insufficient formal evidence. 1, 2, 3

Episodic Cluster Headache

• Galcanezumab is recommended as first-line prophylaxis for episodic cluster headache, representing the strongest evidence-based option according to the 2023 VA/DoD guidelines and American College of Cardiology 1, 2, 3
• Verapamil can be used for episodic cluster headache, though the 2023 VA/DoD guidelines note insufficient evidence to formally recommend for or against it despite extensive clinical use 2, 3
• The European Academy of Neurology recommends verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) for prophylaxis 4

Chronic Cluster Headache

• Verapamil is the prophylactic drug of choice for chronic cluster headache, though evidence remains insufficient for formal recommendation 2, 3
• Galcanezumab is specifically NOT recommended for chronic cluster headache (weak recommendation against) 1, 2, 3
• Clinical studies show complete relief in 55% of chronic cluster headache patients with verapamil, though women respond less favorably (20%) compared to men (69%) 5

Verapamil Dosing Algorithm

• Start with 40 mg in the morning, 80 mg early afternoon, and 80 mg before bed 5
• Increase by 40 mg on alternate days based on attack timing: if nocturnal attacks predominate, increase the evening dose first; if attacks occur upon waking, set an alarm 2 hours before usual wake time to take medication 5
• Most patients require 200-480 mg daily for control, though some need 520-960 mg 5
• Doses used in cluster headache may be double those used in cardiology (360-720 mg commonly used in practice) 1, 6

Critical Verapamil Monitoring

• Obtain baseline ECG before initiating therapy 1
• Monitor PR interval with ECG when using doses >360 mg daily 1
• Do not give verapamil to patients with impaired ventricular function, heart failure, or wide-complex tachycardias 1

Alternative Prophylactic Options

• Lithium is recommended as an alternative treatment, particularly effective in chronic cluster headache, though it has more side effects and longer latency period compared to verapamil 4, 7, 8
• Topiramate is recommended as an alternative prophylactic option 4, 7
• Corticosteroids (at least 100 mg prednisone or equivalent orally, or up to 500 mg IV daily over 5 days) are efficacious as transitional/bridging therapy while establishing prophylaxis 4, 6
• Greater occipital nerve blockade can be used as transitional preventive treatment at the start of a cluster 4, 6

Acute Treatment During Prophylaxis Establishment

• Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg for rapid relief during acute attacks 1, 2, 3, 4
• 100% oxygen at flow rates of at least 12 L/min for 15 minutes for acute treatment 1, 2, 3, 4
• Noninvasive vagus nerve stimulation is suggested for short-term treatment of episodic cluster headache 1, 4

Critical Pitfalls to Avoid

• Do not use galcanezumab if the patient has chronic cluster headache (attacks >1 year without remission) 1, 2, 3
• Limit acute treatment use to no more than twice weekly to avoid medication-overuse headaches 2
• Do not use beta blockers with intrinsic sympathomimetic activity as they are ineffective for headache prophylaxis 2
• Do not confuse acute and prophylactic treatments—oxygen and triptans are for attacks, not prevention 3
• When using higher doses of verapamil (>360 mg), failure to monitor ECG can miss dangerous PR interval prolongation 1