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),...

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 o...

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...

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 ede...