Cluster Headache—Acute and Prophylactic Therapy

Avi Ashkenazi, MD; Todd Schwedt, MD


Headache. 2011;51(2):272-286. 

In This Article

Transitional Prophylaxis

Corticosteroids are often prescribed concurrent with initiation of maintenance prophylaxis in order to quickly obtain cluster control. Oral and intravenous corticosteroids may both provide benefit. Varying doses of oral prednisone, ranging from 10 mg/day to 80 mg/day, were evaluated in a study of 9 episodic and 10 chronic cluster patients.[53] Peak prednisone dose was given for 3 to 10 days and tapered over 10 to 30 days. Complete relief from CH was seen in 11 patients, 3 had 50–99% relief, 3 had 25–50% relief, and 2 patients had no benefit. The ECH and CCH patients had similar responses. Investigators observed that prednisone doses of 40 mg or higher were needed for benefit. Headache recurrence was common during the prednisone taper. Other studies of oral prednisone have had similar results.[54,55] Intravenous corticosteroids, sometimes followed by oral steroids, may also provide benefit for transitional cluster therapy.[56,57] A single high dose of intravenous methylprednisolone (30 mg/kg body weight over 3 hours) delivered on the eighth day of an active cluster period provided 10 of 13 treated patients with 2 or more days of attack cessation.[56] The mean interval between steroid treatment and attack recurrence was 3.8 days. Three patients had complete cluster remission.

Although adequate trials supporting their use are lacking, ergotamine tartrate and DHE may be used for transitional prophylaxis.[58,59] In an open-label study, 23 ECH and 31 CCH patients were admitted to the hospital for treatment with repetitive intravenous DHE.[60] All patients became headache free while being treated with IV DHE: 10 patients (16%) after the first dose, an additional 12 (19%) during the first day of hospitalization, and 22 (34%) more became headache free by the second day of hospitalization. By day 3, greater than 90% of patients were headache free and by day 5 all were headache free. At 3 months after discharge, >90% of ECH patients and 44% of CCH patients remained headache free. Approximately 83% of patients reported no AEs from IV DHE. Reported AEs included nausea, non-cardiac chest tightness, and a metallic taste. Ergotamine tartrate, 3–4 mg per day in divided doses, may be administered for 2 to 3 weeks for transitional prophylaxis.[58,61] Administration just before bedtime may help to prevent nighttime attacks.


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