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Preventing a Cluster Headache Attack

Sphenopalatine ganglia block (SPG block)

SPG block is now possible using a device that is placed by a physician througth the nose. One of these devices is Allevio™. With this device, lidocaine, a local anethetic is used to produce the block. It also blocks the 2nd branch of the trigeminal nerve. This treatment not only treats an acute headache but appears to help prevent future headaches. There is limited controlled data at this time. Most insurances will pay for this therapy at this time. This therapy can safely be done during pregnancy. Bellaire Neurology currently offers this therapy to patients.

SteroidsiHeadache Electronic Headache Diary

Once an attack of cluster headaches has begun, the traditional treatment used to prevent future cluster headaches in the series is steroids. Prednisone is commonly used at doses up to 100 mg a day. Steroids have many potential side effects so many physicians have begun to use it as a second-line agent. If a patient is in the middle of a severe cluster attack in which they feel they have reached their limit, then using prednisone while starting an additional first line agents is reasonable.


The most common first-line agent for cluster prevention is relatively side effect free and is called verapamil. Verapamil is generic and made by many different drug manufacturers. It is available in a long acting, short acting as well as other forms. The most common side effects of verapamil are ankle swelling and constipation. Patients with known cardiac conduction defects should also not take verapamil.

Lithium and Depakote®

When verapamil alone is not effective, it is common to also use lithium or Depakote®, also known as valproic acid. Neurologists have a lot of experience with Depakote® so it is frequently the next agent used by most neurologists; however, in my experience, the lithium is actually somewhat more effective.

There are several toxicity warnings with Depakote®. Depakote® causes severe birth defects in women who take this medication during pregnancy. Since cluster headaches occur mostly in males, this is not much of an issue. The second major toxicity issue is liver dysfunction therefore patient’s who take Depakote® require periodic liver monitoring.

Lithium is harder to use than Depakote® because it has a narrow therapeutic index. This means that the dose between what is effective and what is toxic is relatively small. For this reason, it is common to monitor drug levels weekly while initially increasing the dose when using this drug in order to get a series of cluster headaches under control.

SPG Stimulation

Approved in Europe, SPG stimulation by a device made by Autonomic Technologies appears to potentially treat the painful attack along with preventing future attacks. {Stimulation of the sphenopalatine ganglion for cluster headache treatment. US studies are in progress at the time of this writing (August 2014). {Pathway CH-1: A randomized, sham-controlled stuy. Schoenen J, et.al. Cephalgia 33(10) 816-30}

Other Options

When all of the above do not work, Neurontin® or Topamax® may be tried. This is based on their use in small non-blinded studies. In addition, physicians have tried nasal lidocaine and nasal capsaicin, a synthetic analog civamide. The lack of control data on all of these less common remedies makes it harder to evaluate their effectiveness.