High-dose intravenous methylprednisolone for the prophylactic treatment of cluster headache

Abstract

BackgroundTriptans are effective for immediate relief of episodic cluster headache (CH) but do not reduce the frequency of attacks. Intravenous bolus injection of corticosteroids like methylprednisolone (MP) has been reported to decrease the frequency of CH attacks. We validated the prophylactic efficacy of MP pulse therapy by monitoring CH recurrence over several years following treatment of six consecutive male patients (mean age: 38.8 years, range: 26–54 years) afflicted by frequent (often daily) CH attacks.FindingsTotal MP dose per infusion was 250–500 mg for five patients and 125 mg for the sixth (a diabetic). High-dose MP was administered for 2 or 3 consecutive days in hospital for the first two patients treated. The next four patients received a single bolus injection at presentation, and in some cases a second injection days later at an outpatient clinic. The first two cases treated were also prescribed daily oral prednisolone for at most 6 months while the latter four cases were not. The frequency of CH attacks was markedly reduced in all patients, with intervals between attacks ranging from 4 to 23 months. We noted no apparent adverse events following MP administration.ConclusionsHigh-dose MP therapy reduced CH attack frequency and improved patient quality of life.

Pharmacotherapy for Cluster Headache

“…However, the exact mechanism of action of prednisolone in cluster headache is unknown. Although placebo-controlled trials are lacking, high doses of corticosteroids are highly effective in the treatment of cluster headache, as described in four open-label trials [86][87][88][89] and one case series [90]. There is no consensus on mode of administration (intravenous vs. oral), dosage or duration.…”

Recent advances in the diagnosis and management of cluster headache

“…For oral steroids, a recent randomized controlled trial showed significant improvement with a 17 day course of prednisone (starting at 100 mg daily for five days, then titrating down by 20 mg every three days) 132. Observational studies of various oral corticosteroid pulses, as well as intravenous methylprednisolone, have also been described 133134135136137…”

“…Corticosteroids have been delivered via occipital nerve blocks and via oral tablets; both methods of delivery have shown benefit using a variety of corticosteroids types and dosages. [134][135][136][137][138] Occipital and suboccipital nerve blocks were investigated in a meta-analysis, showing a relative risk ratio of 4.86 for freedom from pain at one month compared with control (across two randomized controlled studies and 66 participants), as well as an overall 50% freedom from pain at one month (across five randomized studies and 156 participants with cluster headache). 128 The exact components of the blocks differed widely.…”

“…132 Observational studies of various oral corticosteroid pulses, as well as intravenous methylprednisolone, have also been described. [133][134][135][136][137] Dihydroergotamine Dihydroergotamine is an ergot compound with clinical effects in cluster headache likely due to its serotonergic activity. 139 Although dihydroergotamine is not specifically recommended by current guidelines, several retrospective analyses support its use in cluster headache.…”

Fremanezumab and Non-High-Dose Galcanezumab for Comorbid Cluster Headache in Patients with Migraine: Three Cases

“…Naratriptan [ 9 , 10 ] and ramelteon [ 11 ] are also considered as alternative prophylactic options [ 9 , 10 ]. Preventative treatments are used on a scheduled basis to reduce the frequency and intensity of headaches [ 12 ]. If it is ineffective, contraindicated, or discontinued due to side effects, the choice of preventative treatment can be difficult [ 13 ].…”