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Alternative Agents for Dihydroergotamine Mesylate
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Cluster Headache Management
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Medication
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Dosing
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Clinical Pearls
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Acute
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Sumatriptan
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6 mg SC
20 mg intranasal spray
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Mild to moderate chest symptoms and distal paresthesia
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1st line for acute attack
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Zolmitriptan
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5 or 10 mg intranasal spray
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Unpleasant taste, somnolence
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Beneficial for patients with moderate pain and long-lasting attacks
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Lidocaine (4%)
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4 intranasal sprays; 0.5 to 0.8 mL of nasal drops
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Unpleasant taste
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Beneficial in patients with contraindications to triptans
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Octreotide
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100 mcg SC
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Gastrointestinal disturbance, injection site reaction
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Last-line due to lack of evidence of treatment efficacy
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Prophylactic
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Verapamil
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≤960 mg daily
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Constipation, arrhythmia, fatigue, bradycardia; no serious AEs reported with daily dose <720 mg
Requires ECG monitoring
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1st choice for eCH and cCH
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Lithium
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Serum concentration 0.7 to 1.2 mmol/L
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Nausea, dizziness, tremor, polyuria
Requires serum concentration, thyroid, and kidney function monitoring
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Avoid use in short bouts of eCH
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Topiramate
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≤200 mg daily
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Paresthesia, depression, drowsiness, dizziness; tolerable in doses <100 mg/day
Monitor for mood changes
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Treatment for eCH and cCH
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Galcanezumab
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300 mg SC monthly
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Injection site pain
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Option for eCH only
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Transitional
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GON injection
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Ipsilateral to pain
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Mild local discomfort at injection site
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Option for eCH only
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Prednisolone
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High-dose IV or PO
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Increased serum glucose
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Only recommended for short-term use
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Frovatriptan
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2.5 to 5 mg daily
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Dizziness, drowsiness
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Limited observed clinical use
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Abbreviations: ECG, electrocardiogram
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