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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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There’s no cure for cluster headaches. The goal of treatment is to help decrease the severity of pain and shorten the headache period.

Acute medication

The purpose of acute treatment is to stop or reduce pain after a cluster headache starts. Because the headache peaks quickly, acute medications must be fast-acting and delivered quickly, using an injection or inhaler rather than oral tablets. You must be ready to take the medication as soon as an attack starts. And you may want to teach family members about your medications so that they’ll be able to help you when you have an attack.

Because the pain of a cluster headache comes on suddenly and may subside within a short time, over-the-counter pain relievers such as aspirin or ibuprofen (Advil, Motrin, others) aren’t effective. The headache is usually gone before the drug starts working. Fortunately, other types of acute medication can provide some pain relief. Treatment of cluster headache is focused more on prevention, with more medication options available to choose from.

Acute treatments include:

* Oxygen. Briefly inhaling 100 percent oxygen through a mask at a rate of 6 to 8 liters a minute provides dramatic relief for most who use it. Occasionally, a higher flow rate may be more effective. The effects of this safe, inexpensive procedure can be felt within 15 minutes. The major drawback of oxygen is the need to carry an oxygen cylinder and regulator with you, which can make the treatment inconvenient and inaccessible at times. Small, portable units are available, but some people still find them impractical. Sometimes, oxygen may only delay rather than stop the attack, and pain may return.
* Sumatriptan. The injectable form of sumatriptan (Imitrex), which is commonly used to treat migraine, is also an effective acute treatment for cluster headache. Some people may benefit from using sumatriptan in nasal spray form, but for most this is not as effective as an injection. Sumatriptan isn’t recommended for people with uncontrolled high blood pressure or ischemic heart disease.

Another triptan medication can be taken orally for relief of cluster headache. Although oral meds isn’t as effective as injectable sumatriptan, it may be an option for people who can’t tolerate other forms of acute treatment.

* Dihydroergotamine. This ergot derivative is available in intravenous, injectable and inhaler forms. Dihydroergotamine (D.H.E. 45, Migranal) is an effective pain reliever for some people with cluster headache. When administered intravenously, the drug requires you to go to a hospital or doctor’s office to have an intravenous (IV) line placed. The inhaler form of the drug works more slowly. The dosage must be limited to avoid side effects, especially nausea.
* Octreotide (Sandostatin, Sandostatin LAR). This drug, a synthetic version of the brain hormone somatostatin, has traditionally been used to control severe diarrhea. However, some studies have shown that the injectable form is an effective treatment for cluster headache and is safe for people with high blood pressure and ischemic heart disease.
* Local anesthetics. The numbing effect of local anesthetics may be effective against cluster headache pain when used in the form of nasal drops.

Surgery

Rarely, surgery is recommended for people with chronic cluster headache who don’t respond well to aggressive treatment or who can’t tolerate the medications or their side effects. Candidates for surgery must have headaches only on one side of the head because the surgery can be performed only once. People with headaches that alternate sides of the head risk the chance that the procedure will be unsuccessful.

Several types of surgery have been used to treat cluster headache. These procedures attempt to damage the nerve pathways thought to be responsible for pain. However, residual muscle weakness in your jaw or sensory loss in certain areas of your face and head may result. The most common procedures are directed at the trigeminal nerve. They include:

* Conventional surgery. Using a conventional invasive procedure, your surgeon cuts part of the trigeminal nerve with a scalpel or uses small burns to destroy part of the nerve. This form of surgery provides relief for most people with chronic cluster headache.
* Radiosurgery. In a procedure called radiosurgery, a focused beam of radiation is used to destroy part of the trigeminal nerve. Radiosurgery is a noninvasive procedure that may have fewer side effects than does conventional surgery, but some studies have questioned the effectiveness and permanency of the results.

Potential treatments

As scientists learn more about the causes of cluster headache, they’re able to develop more selective treatments for the condition. One development that shows promise is the use of a device to stimulate the occipital nerve, which influences the trigeminal nerve. To treat people with frequent cluster headaches, researchers are testing a stimulator — a pacemaker-sized device that sends impulses via electrodes — that is implanted over the occipital nerve. A Mayo Clinic study of implanted occipital nerve stimulators found that the devices reduced chronic headache pain by an average of about half.

Similar research is under way using an implanted stimulator in the hypothalamus, the area of the brain associated with the timing of cluster periods. Stimulation of the hypothalamus in a small number of people with severe, chronic cluster headaches has produced complete and long-term pain relief with no significant side effects.

In addition, researchers are studying new medications for use in treating and preventing cluster headache.

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