What preventive treatment is effective for Cluster Headache
Verapamil is the drug of choice for both episodic and chronic types. It is started at 120 to 240 mg a day and slowly increased (80-mg increase every 3 to 7 days as tolerated) to 480 mg if necessary.
High doses may be required (maximum dose 960 mg/day) depending upon tolerability and response. The drug can be given in both a regular formulation three times daily and an extended-release formulation once a day although, anecdotally, the three-times-daily dosing may be more effective.
With daily doses of 240 mg or higher, baseline and serial electrocardiograms, repeating the electrocardiograms 1 to 2 weeks after a dose change, usually in 80-mg increments, are indicated to monitor for the development of heart block, which becomes more frequent at higher doses.
Topiramate may be effective (starting at 25 mg/day and titrating up to 100 mg/day). Valproic acid is questionably effective.
Melatonin is questionably helpful as a CH preventive. Lithium may be effective for chronic and episodic CHs typically starting at 300 mg bid or tid and increasing every 4 to 5 days based upon levels, with a typical maintenance dose of 900 to 1200 mg daily in three to four divided doses.
The lithium plasma level should be monitored and kept between 0.6 and 1.2 mmol/L.
Lithium has a narrow therapeutic window and numerous significant side effects.