Patients with
cluster headache or any of the
trigeminal autonomic cephalalgias (TACs) are often good candidates for preventive treatment as their
headaches are frequent and severe. While acute and symptomatic
therapies must be used often, they do not alter the course of the cluster period or the duration of the TACs, and they do not usually decrease the frequency of attacks. In this chapter we discuss the aim and the choice of prevention.
Verapamil is considered the first choice for prevention of
cluster headache, but as with all of the medications to be mentioned, it has various adverse effects to be aware of. Other frequently used preventives for cluster include
lithium carbonate,
methysergide where available,
methylergonovine,
clonidine,
melatonin,
valproate,
gabapentin,
topiramate, and others. Several other medications can be used as
bridge therapy, to decrease the frequency of cluster temporarily, giving time for the preventives to begin to work. The most commonly used bridge
therapies are 7-21 days of
prednisone at high and then tapering doses and ergots such as
ergotamine tartrate and
dihydroergotamine. Patients with
chronic cluster headache who are unresponsive to all medical
therapies can be considered for occipital nerve stimulation and various
surgical procedures such as ganglyogliolysis of all three branches of the ipsilateral trigeminal nerve at the root entry zone. A somewhat controversial but highly successful procedure, at least as done by the neurosurgeons in Professor Bussone's group at the Institute of Neurology in Milan, has been
deep-brain stimulation of the posterior hypothalamus. Other TACs, such as short-lasting unilateral neuralgiform
headache attacks with conjunctival injection and tearing (SUNCT), can be hard to treat effectively with medications, but the
paroxysmal hemicranias and cluster
tic respond somewhat better to traditional
therapies.