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Because the cause of cluster headache is unknown, you can’t prevent a first occurrence. However, a preventive strategy is crucial for managing cluster headache because trying to treat it with acute drugs only can seem hopeless. Prevention can help reduce the frequency and severity of the attacks and the risk of rebound headaches. Preventive medications can also increase the effectiveness of acute medications.

Preventive medications for cluster headache are generally used for either a short-term (transitional) strategy or a long-term (maintenance) strategy. The short-term medications work quickly but may have undesirable side effects. Long-term medications take effect more slowly but can be used safely throughout the cluster period.

Whenever a cluster period starts, you’ll likely start taking a long-term medication, many times accompanied by a short-term medication. After a couple of weeks, you’ll discontinue use of the short-term medication but continue with the long-term drug.

Short-term prevention

Short-term medications can prevent headache attacks during the period of time it takes for one of the long-term drugs to become effective. The main short-term preventive medications are corticosteroids and ergotamine. A nerve block also may be effective, particularly for some people who can’t tolerate the other medications.

* Corticosteroids. Inflammation-suppressing drugs called corticosteroids are fast-acting preventive medications. They belong to a general family of medicines called steroids. Your doctor may prescribe corticosteroids if your cluster headache condition has only recently started or if you have a pattern of brief cluster periods and long remissions. Although corticosteroids are an excellent treatment for several days, serious side effects make them inappropriate for long-term use.
* Ergotamine. Ergotamine available as a tablet that you place under your tongue or available as a rectal suppository, can be taken before bed to prevent nighttime attacks. Ergotamine medications are effective for short periods but shouldn’t be used for more than two to three weeks.
* Nerve block. Injecting an anesthetic (numbing agent) and corticosteroid into the area around the occipital nerve, located at the back of your head, can prevent pain messages from traveling along that nerve pathway. The occipital nerve converges with the trigeminal nerve, which connects to all the pain-sensitive structures in your skull. An occipital nerve block can be useful for temporary relief until long-term preventive medications take effect.

Long-term prevention

Long-term medications are taken during the entire cluster period. Some people with chronic cluster headache don’t respond well to the use of one long-term medication. In this situation, your doctor may recommend that you take two or more long-term medications simultaneously.

* Calcium channel blockers. The calcium channel blocking agent verapamil is often the first choice for preventing cluster headache, although the way verapamil works with cluster headache isn’t well understood. The medication may be used from the start of a cluster period until three to four weeks after the last headache. Then its use is gradually tapered and discontinued under your doctor’s direction. Occasionally, longer term use is needed to manage chronic headache. Constipation is a common side effect of this medication, as well as dizziness, nausea, fatigue, swelling of the ankles and low blood pressure.
* Lithium carbonate. Lithium which is used to treat bipolar disorder, is also effective in preventing chronic cluster headache. Side effects include tremor, increased thirst, diarrhea and drowsiness. Your doctor can adjust the dosage to minimize side effects. While you’re taking this medication, your blood will be drawn at regular intervals to check for the development of more serious side effects, such as liver or kidney damage.

Preventive medications under evaluation

Other preventive medications used for cluster headache include the hormone melatonin, capsaicin and anti-seizure medications such as divalproex and topiramate.

In addition, you may help reduce your risk of future attacks by avoiding alcohol and nicotine, which often precipitate cluster headaches.

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