What preventive medications do you recommend for patients with cluster headaches?  

As per the 2016 AHS guidelines, here are the recommended treatments for cluster headache prevention: Level A: Suboccipital steroid injection Level B: Civamide 0.025% 100 uL nasal spray daily Level C: Verapamil 360 mg, Lithium 900 mg, and warfarin (INR goal 1.5-1.9, reserved for refractory patient...

When someone presents with cluster headache, there are usually 3 therapeutic approaches that are needed: Acute Treatment: injectable or nasal spray triptans (because the rapid onset of action is needed given the severity of the pain), high flow oxygen (100% FiO2 with mask, not nasal cannula). Both ...

I certainly agree with Dr. @Sheikh and have seen the most success with Emgality; high dose verapamil (360 mg and above) being an effective but distant second. Keep in mind that Emgality is FDA-approved for the treatment of episodic cluster headaches (and the prevention of migraine) only, not chroni...

Emgality is a new cGRP inhibitor that has been approved, along with verapamil and lidocaine. Occipital injections can be helpful. A course of steroids may also be an option.

Recently, there was an excellent review published in JAMA Neurology that includes useful tables and figures for reference. See Tables 1 and 2 (Diener et al., PMID 36648786).

I had the best long-term success with Verapamil and Emgality. The rest of the above either have side effects or temporary effects or are used as PRN. High-flow oxygen can also help.

My favorite medication for preventing episodic cluster headaches is verapamil. I typically start with a dosage of 80 mg tid and then gradually increase to 160 mg tid or even higher, depending on the patient's response. However, I always caution patients about potential side effects such as pedal ede...