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• Weight gain
• Osteoporosis
• Infection
• Intestinal bleeding
• Hypertension
• Glaucoma
• Fluid retention

Some cluster patients may require 2 or more preventive medications to be combined in order to achieve improvement.

Ergot Alkaloids

Ergot alkaloids are a class of drugs which decrease inflammation and reverse dilation of blood vessels around the brain. They are contraindicated for individuals with peripheral vascular disease. There are two medications in this class which may be used to treat cluster headache:

• Dihydroergotamine mesylate (DHE-45)
• Ergotamine

Dihydroergotamine mesylate (DHE-45) has been used for several decades as an effective abortive agent for acute cluster headaches. When administered intravenously, DHE-45 provides effective relief of cluster headache within 15 minutes. When administered either intramuscularly, subcutaneously, or as a nasal spray, the time to relief is slightly longer. Because cluster attacks may be of short duration and tend to become severe so quickly, it is impractical in that time frame to be able to reach an emergency room to initiate an intravenous drip of the medication. Subcutaneous and intramuscular delivery of DHE-45 are somewhat more suited for self-administration. Even so, this medication does not offer a long-term solution to patients with cluster headache. DHE-45 is most effective in reducing the pain intensity of headaches but does not affect the frequency or duration of the attacks.

Ergotamine has been used for treatment of cluster headache for more than 50 years. It is effective for achieving rapid suppression of cluster attacks. When the cluster episode terminates, ergotamine can be easily discontinued.

Ergotamine is more convenient to use since it can be taken orally and has been reported to prevent nighttime headaches when taken 1-2 hours before retiring for the night.

Ergotamine is contraindicated in patients with:

• Peripheral vascular disease
• Coronary artery disease
• Uncontrolled hypertension
• Pregnancy

Oral or suppository forms of ergotamine used to be the mainstay of cluster abortive therapy but since sumatriptan was introduced, it is not as widely used anymore. The most notable side effects of ergotamine include:

• Arterial spasm
• Dependence with long-term use

Ergotamine cannot be combined with sumatriptan.

Intranasal Lidocaine

Intranasal lidocaine is given as nasal drops or spray and is administered deep in the nostril on the same side as the headache (ipsilateral) in order to block the pain close to the point of origin. Some patients achieve mild to moderate relief within 10 minutes of lidocaine administration but only a few achieve complete relief. Lidocaine is used as an adjunctive (additional or supportive) treatment but not as a stand-alone therapy since it is not as effective as other available medications.

Analgesics

Analgesics are generally not effective since they take a relatively long time to be absorbed into the bloodstream and, therefore, cannot overcome the extreme pain of a cluster headache that intensifies quickly.

In summary, individuals who suffer from chronic cluster headache find the greatest relief from sumatriptan and corticosteroids, however long term side effects of corticosteroids can be very severe so they are administered only for the short-term. Many patients also benefit from oxygen therapy. Chronic cluster headache patients require more aggressive therapy. Some patients reach a point where they need to be admitted to a hospital either for detoxification from all of their medications or, during a particularly difficult bout with unremitting pain, for "heavy-duty" intravenous treatment with drugs such as corticosteroids and ergotamine.

Prophylactic Treatment