Cluster Headache Treatment Tips and Nuances

This transcript has been edited for clarity. Indu Subramanian, MD: Hi, everyone. Welcome to Medscape. I’m so excited to have you all join us and to hear about treatments of cluster headache from my friend and colleague, Professor Andrew Charles. He is a neurologist and professor of neurology here at UCLA, which is where I also work. He is the director of the Goldberg Migraine Program here, and he’s really a world expert in cluster headache.We have another episode to check out where we define this and talk about the diagnosis, but we’re going to be focusing on treatment in this session. Welcome, Andy.Andrew C. Charles, MD: Thanks. Good to be here.Subramanian: We talked about how hard it is sometimes to identify these patients, how they get misdiagnosed, and how it is something that can be very devastating and very uniquely characterized in terms of symptoms. I’d love to focus on how we treat this. Tell us about the current treatment paradigms and how we can help these patients.Acute Therapies for Cluster Headache Charles: In headache medicine, we typically divide things into acute therapies, meaning those that one takes when an attack occurs, vs preventive treatments, which are those used to stop them from happening in the first place. In this particular circumstance, we automatically use both. With cluster headache, we always use both acute treatments and preventive treatments because the attacks are so severe and also because the acute treatments are often not that effective. We need to basically intervene with both acute and preventive treatments. On the acute side, to discuss those briefly, there are a couple of differences between cluster and migraine. One is that a cluster headache can respond to inhaled oxygen. For some people, it’s quite effective as an acute treatment, and that’s not typically true for migraine headache. Migraine attacks don’t typically respond to oxygen. Cluster attacks also respond to triptans, like migraine does, but the problem with them is that triptans usually take about an hour to work, and a cluster attack usually lasts only about 2 hours. Getting something into the system quickly enough to actually abort an attack is something that’s very important. Many people resort then to sumatriptan injections because those have the fastest onset of action as an acute treatment.Unfortunately, the new calcitonin gene-related peptide (CGRP)-targeting therapies, which are so effective for migraine, are not necessarily as effective for cluster headache. That then leaves us with somewhat limited options in terms of acute treatment of cluster. The other problem with cluster is that because attacks can occur multiple times per day, it’s very easy to get into a pattern of what we call medication overuse, where you’re basically taking these acute medications all the time, and that may then interfere with the efficacy of preventive treatments — or in some cases, we think it might even prolong the duration of these episodes of cluster.Basically, oxygen and triptans are a mainstay of what we use.The Art of Prevention for Cluster Headache Subramanian: Tell us a little bit about the preventive side, too.Charles: This is where there becomes really an art, and there’s not any necessarily generally accepted treatment paradigm for prevention. I’ll tell you what I do, and I think most will agree, but I’ll point out where some may disagree. We often will use a short course of steroids as a bridge therapy as we’re beginning other preventive treatments. I will say cluster is different from migraine and many other neurologic disorders where we try to streamline therapies and use as few as possible, and find the one or two things that work. Whereas with cluster headache, we basically throw everything we have at it when it starts to try to break people out of the cycle, and then we pull back. It’s a very different principle of treatment. Anyway, we start with steroids. We use dexamethasone rather than prednisone. We actually use it broadly for headache disorders because of a variety of properties that we won’t get into. Dexamethasone is something that I typically will put everybody on at the beginning of their bout.Verapamil, the calcium-channel blocker, is the other standard treatment to get people out of a cluster attack. We will typically use the short-acting preparations, but we can sometimes also get away with using the long-acting preparation of verapamil 120 mg or 240 mg. Some people get up to astronomically high doses of verapamil, like 720 mg or even higher, but that’s what actually is required for some people. Pretty much everybody we’re using verapamil with. One of the out-of-the-box treatments that we use, and this may be related to the circadian features of cluster, is high-dose melatonin. We use 10 mg of melatonin routinely as a treatment. This is one that is particular to us. I’m not sure it’s widely used, but we found that to be quite helpful for some individuals. Then finally, one of the CGRP-targeting monoclonal antibodies, galcanezumab (Emgality is the brand name), was shown to be effective as a treatment for cluster headache. We do use that one fairly routinely. Disappointingly, like with the acute treatments, it’s not as spectacularly effective, particularly as a monotherapy, as in the setting of migraine, where it can be really effective. It still can be very helpful.There’s a number of other treatments, but those really are the main ones. Steroids, verapamil, melatonin, and galcanezumab.Subramanian: It sounds like a very complex approach, but I know in our experience, the few patients that we’ve shared, it has been life-changing for some of these folks. Thank you so much for joining us today, Andy. I appreciate it.Charles: My pleasure.Subramanian: See you, everyone.