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It is very important for patients suffering from chronic cluster headache to prevent individual attacks during a cluster episode. It is advisable for all cluster headache patients to take some sort of prophylactic medication in order to reduce their pain and suffering during a cluster headache cycle or episode. When the cluster cycle ends, medication is typically withdrawn. For some individuals who experience many short intense headaches, abortive treatment is difficult to maintain.

The goals of prophylactic treatment include:

• Suppression of headaches
• Maintaining suppression for the expected duration of the cluster episode
• Reduce the frequency, duration, and severity of headaches if it's not possible to suppress them completely

There are several types of prophylactic medications that may be attempted to evaluate and optimize individual efficacy, including:

• Verapamil
• Corticosteroids
• Lithium
• Valproic Acid
• Topiramate
• Methysergide

Verapamil

Verapamil, a calcium channel blocker, is the first-line preventive medication for cluster headache. It is taken orally and is highly effective in reducing the frequency of cluster attacks, though many patients need higher doses than suggested by the manufacturer to obtain relief. It works well for both episodic and chronic cluster headache but prevention of chronic cluster headaches may require a higher dosage than for episodic cluster headaches. Verapamil can be combined with other agents used for cluster headache (e.g., lithium, sumatriptan, ergotamine, and corticosteroids). Since verapmil is so effective, it is also used for continuous treatment for chronic cluster headache.

Verapamil is available in two formulations - regular and extended release. The regular formulation is more effective than the extended release formulation.

Adverse effects of verapamil are not common but may include:

• Bradycardia (slow heart rate)
• Postural hypotension (low blood pressure when changing positions)
• Constipation
• Fatigue
• Edema (water retention)
• Gastrointestinal upset

Monitoring of the heart by electrocardiogram at predetermined intervals is recommended.

Corticosteroids

Prednisone is effective as a prophylactic agent in cluster headache but is given for only limited periods of time since the side effects can be quite significant. Under certain circumstances, for example when the patient cannot obtain relief, the physician may choose to use corticosteroids as a transitional drug until a longer-acting prophylactic medication takes effect.

Lithium

Lithium is still considered a mainstay of cluster preventive therapy and is effective for episodic as well as chronic cluster headache. The positive effects of lithium usually become apparent within a few days of commencing treatment. Long-term effects are not yet known but some patients develop a tolerance for the drug which reduces its efficacy. Lithium may be combined with other medications (e.g., ergotamine or corticosteroids) for severe cluster headache.

Lithium has undergone investigation in several clinical trials and has been shown to achieve good to excellent result in up to 75% of individuals with chronic cluster headache, with some individuals reporting improvement for up to 4 years. Some patients with chronic cluster headache have reported that when they stopped taking lithium, they transitioned from chronic cluster headache to episodic cluster headache. Lithium is reported to be effective in approximately 60% of patients with episodic cluster headache.