Corticosteroid treatment in cluster headache: evidence, rationale, and practice

The use of corticosteroids in the treatment of cluster headache (CH) is commonplace and has been a mainstay of clinical practice for this indication for 50 years. The published evidence supporting this practice is weak, with no methodologically rigorous or large-scale controlled trials executed. Nonetheless, the clinical experiences of practitioners and the conclusion of investigators provide a clear signal of benefit from corticosteroid use in CH. The pathophysiologic explanation for this beneficial effect is unknown, but corticosteroid influences on inflammatory, hypothalamic-pituitary-adrenal, histaminergic, and opioid systems have been proposed. Best-practice parameters are unclear, but the professional consensus is that corticosteroids generally are effective for arresting CH attacks, only if administered in relatively high doses, and that safety concerns warrant courses of 4 weeks or less. Concomitant use of other prophylactic agents for CH in addition to corticosteroids usually is advisable because attacks often recur when the corticosteroid dose is tapered.