19th June 2023

Cluster Headache

Diagnosis

Cluster headache is a primary headache disorder characterised by:

• Severe unilateral periorbital pain
• Ipsilateral autonomic symptoms such as conjunctival injection, lacrimation, eyelid oedema, nasal congestion, rhinorrhoea, forehead and facial flushing or sweating
• Typically symptoms last < 3 hours

As the name suggests, these headaches present as clusters, occurring in series lasting for a period (weeks or months) separated by intervals of remission. The different classifications of cluster headaches are based on their frequency:

• Episodic – occur in periods lasting 7 days to 1 year with pain-free intervals of at least 1 month.

• Chronic – occurs in periods for more than 1 year without being pain free or with periods of pain free intervals of less than 1 month.

Clinical features

• Unilateral periorbital pain with autonomic symptoms as described above
• Attacks last 15 min – 3 hours
• Attacks of headache may show circadian periodicity
• Males are affected four times more than females. Age group 20-40 years.

Management

• Subcutaneous or nasal triptan
• Zolmitriptan nasal spray (unlicensed)
• Offer short burst oxygen therapy – 100% oxygen at 12-15 litres/min via a non-rebreather face mask for 15-20 mins. Provision of home oxygen.

NICE does not recommend offering paracetamol, NSAIDs, opioids, ergots or oral triptans for acute treatment.

Pharmacological Prevention

• Verapamil
• Lithium (unlicensed)

Paroxysmal hemicrania

Paroxysmal hemicrania, like cluster headache, is a trigeminal autonomic cephalgia. The presentation is similar and can include headache and autonomic symptoms like those of cluster headaches. However, chronic paroxysmal hemicrania have an increased frequency of attacks (up to 15 in 24 hrs) and tend to have a shorter duration of attacks (5-30 mins) compared to cluster headaches. Paroxysmal hemicrania often responds well to indomethacin therapy.