PassFinals
Neurology

Cluster Headache

A trigeminal autonomic cephalalgia causing recurrent, very severe strictly unilateral orbital or temporal attacks with ipsilateral cranial autonomic features, restlessness and a cluster pattern.

In a nutshell

Cluster headache causes short, excruciating strictly unilateral orbital attacks with ipsilateral autonomic signs and restlessness, recurring in bouts. Treat acute attacks with high-flow oxygen and/or a fast-acting triptan; prevent bouts with specialist-led verapamil and ECG monitoring.

Classic presentation

A patient paces during repeated nocturnal attacks of severe unilateral orbital pain with a red, watering eye and blocked nostril on the same side.

Key points

  • Strictly unilateral orbital or temporal pain plus ipsilateral autonomic signs and restlessness is the classic pattern.
  • Attacks last 15 to 180 minutes and occur up to 8 times daily in bouts.
  • Use 100% oxygen at at least 12 L/min via non-rebreathing mask and/or subcutaneous or nasal triptan for acute attacks.
  • Do not use oral analgesics or oral triptans for acute cluster headache.
  • Verapamil prevention needs specialist input and ECG monitoring; first bout needs imaging discussion.

First-line investigation

Clinical diagnosis plus specialist discussion of neuroimaging for a first bout or atypical presentation.

Management

Recognise red flags and the cluster phenotype

  • Check first bout, atypical features, glaucoma, thunderclap, infection, neurological deficit and suicidal distress before settling on primary cluster headache.1,2

Abort the attack rapidly

  • Offer high-flow 100% oxygen through a non-rebreathing mask and/or a subcutaneous or nasal triptan; avoid oral analgesics and oral triptans.1,5

Prevent attacks during the bout

  • Consider verapamil with specialist advice and ECG monitoring before and during treatment.1,3,4

Escalate atypical or refractory disease

  • Discuss imaging for a first bout, seek specialist advice when verapamil fails, and urgently reassess persistent or changed symptoms.1,6

Support the bout and safety-net

  • Use a diary to document bouts and treatment response, explain oxygen safety and ask about mood and suicidal thoughts during severe attacks.1,2

Exam traps

  • Cluster patients are restless; migraine patients more often lie still.
  • Oral analgesics and oral triptans are not the acute treatment for cluster headache.
  • A painful red eye with reduced vision or a fixed pupil suggests glaucoma, not routine cluster headache.
  • Verapamil is specialist/off-label for cluster prevention and requires ECG surveillance.

Illustrations

Cluster headache phenotypeComparison of unilateral orbital pain, ipsilateral autonomic features, restlessness and short repeated attacks.PassFinals · original
Oxygen and triptan treatmentAcute cluster-headache pathway showing non-rebreathing oxygen and fast-acting triptan options.PassFinals · original

Key sources

  1. NICE CG150: Headaches in over 12s, recommendations (CG150, updated 3 June 2025)
  2. NHS: Headaches (NHS symptom information)
  3. NHS: About verapamil (NHS medicine information, reviewed 13 March 2025)
  4. BNF: Verapamil hydrochloride (BNF medicine monograph)
  5. BNF: Sumatriptan (BNF medicine monograph)
  6. NICE CG150: Update information (CG150 update, 3 June 2025)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.