5th August 2024

Cluster headaches

Cluster headaches are characterised by severe unilateral pain around the eye and side of the face associated with autonomic features including nasal congestion, ptosis and lacrimation. Patients are generally agitated during an attack and move around a lot. Males are more likely to be affected than females.

Episodes last 15-180 minutes and occur in clusters lasting from a few weeks to 3 months with an attack-free period of at least 3 months. There is also a chronic form of the disorder where the clusters last for 1 year or more or the remission period is less than 3 months.

Cluster headaches are classified as a subtype of trigeminal autonomic cephalalgia in the ICHD-3 criteria. The other subtypes are listed in the table below.

• Acute attacks are treated with high flow oxygen and/or subcutaneous or nasal triptans. Intranasal lidocaine can be used instead of triptans, for example in those with coronary artery disease where triptans are contraindicated.
• First line prophylactic treatment is verapamil.
• As preventative treatments can take a few weeks to work, corticosteroids can be started at the same time as verapamil as a bridging therapy. High-dose prednisolone has been shown to induce remission quickly, however it should be weaned after 5 days due to the risks of long-term steroid use.