Cluster headaches are considered to cause the most severe pain of any type of headache. Once the cluster period begins, headaches occur once or several times a day with each attack lasting 1-3 hours. We do have a new preventive treatment for cluster headaches – monthly injections of a drug that was first approved for migraines, galcanezumab (Emgality). This drug, however, does not help everyone. Even when it does, it can take up to a week to begin helping.
For quick relief, we continue to use a 10-14 day tapering course of steroid medicine, prednisone. Prednisone often works only while the patient is taking it. It is a powerful drug with many potential side effects. This is why it is mostly used for a short time to serve as a bridge that allows another preventive drug to begin working. The most popular preventive medicine for cluster headaches besides Emgality is a blood pressure drug, verapamil.
German researchers just published the results of a double-blind controlled study of prednisone for cluster headaches. They started half of the 116 patients with cluster headaches on placebo and the other half, on 100 mg of prednisone. After five days on 100 mg, they reduced the dose by 20 mg every 3 days. At the same time, all patients were started on verapamil.
In the first week, those on prednisone had a mean of 7.1 attacks, while those on placebo had 9.5 attacks. Statistically, this was a highly significant difference. Having 2-3 fewer attacks in a week may not seem that significant, but only to those who’ve never had a cluster headache. And these mean numbers hide the fact that for some prednisone is highly effective, while for others, not at all. Also, the pain intensity was lower and the number of attacks in the prednisone group remained lower during the fourth week.
Clusters tend to occur once or twice a year or once every few years. Once we find a treatment that works well, including prednisone, it tends to work well for every subsequent attack
No serious side effects occurred in the prednisone group. However, this was a relatively small study and we know that serious side effects can happen even from a short course of prednisone.
About a quarter of my patients get very good immediate relief from an occipital nerve block and avoid taking prednisone. Some of these patients don’t even need Emgality or verapamil. They stay headache-free until the next cluster period.
Even when a preventive treatment is very effective, occasional attacks may still occur. This is why I also always prescribe treatment to stop an individual attack. This is usually sumatriptan injections and occasionally, zolmitriptan nasal spray or inhalation of oxygen.
