Headaches: Cluster - Medications

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Ergotamine. Drugs containing ergotamine (sometimes called ergots) cause contractions of smooth muscles, including those in blood vessels, and are commonly used for migraine. Taking them before an expected cluster attack produces good results for many patients. One ergot-derived drug called dihydroergotamine (DHE) is administered by injection, which can be performed by the patient at home. It is also available as a nasal spray (Migranal), which may have fewer side effects than the injection. Ergotamine itself is available in oral tablets (Ergomar, Wigraine, Ercaf) and in rectal suppositories (Cafergot). Cafergot, Wigraine, and Ercaf contain caffeine. An ergotamine inhaler is being investigated.

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Side effects of ergotamine include nausea, dizziness, tingling sensations, muscle cramps, and chest or abdominal pain. Ergotamine has toxic effects at high levels. It also causes persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke. Pregnant women, people over age 60, and those with serious, chronic health problems, particularly those of the heart and circulation, should avoid these medications altogether. As with other migraine drugs, if ergotamine is taken more than twice a week, the patient is at risk for rebound headaches when the drug is withdrawn, although cluster headaches appear to be at lower risk for this effect than other types of headaches.

Corticosteroids. A corticosteroid is very useful as a transitional drug for stabilizing patients after an attack until a maintenance drug, such as a calcium-channel blocker, begins to take effect. The corticosteroid drug prednisone is effective in up to 90% of patients with episodic cluster headaches. The drug is typically taken for a week and then gradually tapered off. If headaches return, then it may be administered again. Unfortunately, long-term use of steroids can lead to serious side effects so they cannot be taken for on-going prevention.

Other Drugs Investigated for Prevention

Baclofen (Lioresal). Baclofen is a drug that relaxes muscle spasms. Small studies have reported some success. For example, in a 2001 study, 12 of 16 patients reported an end of attacks within a week and another one became headache-free by the second week. (The remaining three patients became worse, however, and required other drugs.) Three of the patients who improved experienced an additional cluster cycle, which cleared when they took another course of baclofen.

Botulinum. Botulinum toxin A (Botox) injections are being used for several conditions requiring muscle relaxation, including smoothing wrinkles. (This potentially deadly toxin is very safe when minuscule amounts are injected into small muscles.) Botox has shown promise for migraine and tension headache sufferers and is now being studied for cluster headaches as well. It is too early yet to gauge any real benefits.