Low-Dose Corticosteroids for Chronic Cluster Headache
Low-dose oral corticosteroids should be used only as short-term transitional therapy (typically 5 days at 100 mg prednisone followed by a 12-day taper) during acute exacerbations of chronic cluster headache, not for long-term prevention. 1, 2, 3
Role of Corticosteroids in Cluster Headache Management
Corticosteroids serve as transitional prophylaxis to bridge the gap while titrating long-term preventive medications like verapamil, which can take weeks to reach therapeutic effect. 2, 3
Evidence-Based Transitional Protocol
Prednisone 100 mg daily for 5 days, followed by tapering of 20 mg every 3 days (total 17-day course), significantly reduces attack frequency in the first week compared to placebo (mean 7.1 vs 9.5 attacks, p=0.002). 1
This regimen should be initiated concurrently with verapamil up-titration (starting 40 mg three times daily, increasing to 120 mg three times daily by day 19). 1
Short courses of high-dose oral corticosteroids are applicable mainly for patients with high-frequency attacks (>2 per day) during episodic cluster periods. 3
Why Not Long-Term Use
Corticosteroids are explicitly contraindicated for long-term prevention due to well-established risks of serious adverse effects with prolonged use, including metabolic complications, osteoporosis, cardiovascular disease, and immunosuppression. 2, 3
The evidence base supports corticosteroids only as transitional therapy, not maintenance prophylaxis. 2, 3
When used appropriately, corticosteroids can be administered safely up to six times annually for recurrent cluster periods. 4
Long-Term Preventive Strategy for Chronic Cluster Headache
First-Line Prevention
Verapamil remains the cornerstone of maintenance prophylaxis for both episodic and chronic cluster headache, though current evidence is insufficient to make a strong recommendation. 5, 6, 3
Minimum effective dose is typically 240 mg daily, with many patients requiring higher doses. 7
Baseline ECG and PR-interval monitoring required when doses exceed 360 mg daily due to cardiac arrhythmia risk. 7, 3
Important Limitation for Chronic Cluster Headache
Galcanezumab is NOT recommended for chronic cluster headache (weak recommendation against), despite being first-line for episodic cluster headache. 5, 8
The distinction between episodic (remission periods) and chronic (continuous attacks >1 year without remission) is critical for treatment selection. 8
Second-Line Options
Lithium is an alternative first-line agent, particularly for chronic cluster headache, but requires monitoring of liver and kidney function before and during treatment. 6, 3
Topiramate serves as second-choice if verapamil and lithium are ineffective, contraindicated, or discontinued due to side effects. 6
Acute Treatment During Exacerbations
While establishing or adjusting prophylaxis, acute attacks should be treated with:
Subcutaneous sumatriptan 6 mg (70-82% efficacy within 15 minutes) as first-line. 7, 9
100% oxygen at ≥12 L/min for 15 minutes (no cardiovascular contraindications, safer than triptans). 7, 9
Intranasal zolmitriptan 10 mg or intranasal sumatriptan 20 mg as alternatives. 7, 9
Critical Pitfalls to Avoid
Do not confuse transitional therapy with long-term prevention—corticosteroids treat the acute worsening period, not ongoing prophylaxis. 8, 2
Do not extend corticosteroid courses beyond 2-3 weeks due to cumulative toxicity risk. 1
Do not use galcanezumab if the patient has progressed to chronic cluster headache (attacks >1 year without remission). 8
Do not increase verapamil without ECG monitoring—cluster headache dosing may be twice typical cardiology doses. 7
Do not combine triptans with ergotamine derivatives within 24 hours due to additive vasoconstrictive effects. 7, 9