What preventive medications do you recommend for patients with cluster headaches?

As per the 2016 AHS guidelines, here are the recommended treatments for cluster headache prevention:

• Level A: Suboccipital steroid injection
• Level B: Civamide 0.025% 100 uL nasal spray daily
• Level C: Verapamil 360 mg, Lithium 900 mg, and warfarin (INR goal 1.5-1.9, reserved for refractory patients), Melatonin 10 mg

New since these guidelines:

1. Emgality 300 mg monthly
2. GammaCore neuromodulation

Guideline Reference:

Robbins et al., PMID 27432623

When someone presents with cluster headache, there are usually 3 therapeutic approaches that are needed:

Acute Treatment: injectable or nasal spray triptans (because the rapid onset of action is needed given the severity of the pain), high flow oxygen (100% FiO2 with mask, not nasal cannula). Both of these have shortcomings. Triptans are quite effective but the benefit lasts hours so the headache may recur later in the day. High-flow oxygen works in 70-75% of patients but is cumbersome if you want to leave the house. Injectable DHE or Trudhesa may be better options for those who have recurrent cluster headaches in a day.

Bridging Therapy: It takes time for preventive therapy to work so many will need treatment to tide them over. Although st...

Emgality is a new cGRP inhibitor that has been approved, along with verapamil and lidocaine. Occipital injections can be helpful. A course of steroids may also be an option.

I certainly agree with Dr. @Dr. First Last and have seen the most success with Emgality; high dose verapamil (360 mg and above) being an effective but distant second.

Keep in mind that Emgality is FDA-approved for the treatment of episodic cluster headaches (and the prevention of migraine) only, not chronic cluster headaches. The dosing is also different for cluster headache prevention (300 mg per month) in comparison to migraine (120 mg per month). I discontinue Emgality use after my patient has gone over 30 days without a cluster attack (out of their episodic cluster phase). In my experience, patients will typically see improvement within the first week after initiating Emgality. Verapamil, on the other hand, takes considerably longer to ...

Recently, there was an excellent review published in JAMA Neurology that includes useful tables and figures for reference. See Tables 1 and 2 (Diener et al., PMID 36648786).

I had the best long-term success with Verapamil and Emgality. The rest of the above either have side effects or temporary effects or are used as PRN. High-flow oxygen can also help.

My favorite medication for preventing episodic cluster headaches is verapamil. I typically start with a dosage of 80 mg tid and then gradually increase to 160 mg tid or even higher, depending on the patient's response. However, I always caution patients about potential side effects such as pedal edema, low blood pressure, heart block, etc.

While there are other medications available such as galcanezumab SC and devices like the gammaCore, I often initiate treatment with verapamil.

I agree with everyone who has written many other ways to treat cluster headaches. Although verapamil may not be as extensively studied as galcanezumab, it remains one of the quickest and most effective treatments for cluster headaches, with few adverse events repor...