Quick answer
What is cluster headache?
Cluster headache is a rare but extremely severe primary headache — intense pain around one eye, often with watering eye, blocked nose, and droopy eyelid on the same side. Attacks last 15 to 180 minutes and occur in clusters (weeks to months) often at the same time daily — especially during sleep. Much more common in men. Acute treatment — high-flow oxygen through mask and sumatriptan injection or nasal spray. Verapamil is main preventive. See a GP urgently for new severe one-sided headaches around the eye — neurology referral for diagnosis and specialist treatment.
Cluster headache — the suicide headache
Cluster headache belongs to trigeminal autonomic cephalalgias (TACs) — primary headache with severe unilateral pain and ipsilateral autonomic features.
~1/1000 prevalence — 3:1 male — peak 20–40
Nicknamed “suicide headache” — pain intensity unmatched among primary headaches
Attack characteristics
Diagnostic criteria (brief):
- Severe unilateral orbital/temporal/supraorbital pain
- 15–180 minutes duration
- Frequency every other day to 8 daily
- At least one ipsilateral autonomic sign:
- Conjunctival injection
- Lacrimation
- Nasal congestion/rhinorrhoea
- Forehead/facial sweating
- Miosis/ptosis
- Eyelid oedema
Restlessness — key differentiator from migraine
Episodic vs chronic
Episodic cluster:
- Cluster periods — weeks to months
- Remission ≥3 months
Chronic cluster:
- No remission over 12 months
- Harder to treat
Circadian and circannual rhythm — spring/autumn onset common
Triggers
Alcohol — reliable trigger during cluster period only
Nitroglycerin — medical provocation test
Sleep — attacks often 1–2 hours after falling asleep
Strong odours — solvents
Acute treatment
| Treatment | Details |
|---|---|
| Oxygen | 12–15 L/min, non-rebreather, 15 min |
| Sumatriptan SC | 6 mg — onset ~10 min |
| Sumatriptan nasal | 20 mg if needle aversion |
| Zolmitriptan nasal | Alternative |
Avoid:
- Oral triptans alone — too slow
- Oxygen with significant COPD without advice
Prevention
Verapamil:
- Start low, titrate — up to 960 mg/day
- ECG before and during — heart block risk
Bridge:
- Prednisolone taper — rapid cluster control short term
Other:
- Lithium
- Topiramate
- Greater occipital nerve block
- Galcanezumab — episodic cluster
Secondary causes — must exclude
MRI brain with attention to pituitary and cavernous sinus
Red flags for secondary:
- Atypical autonomic pattern
- Abnormal examination between attacks
- Older age first onset
Living with cluster
Headache diary — timing proves cluster pattern
Workplace adjustments — predictable sick leave during cluster
OUCH UK peer support
Suicidal ideation during attacks common — crisis plan
Waking same time nightly with eye pain and tears — not sinusitis until proven — GP + neurology — oxygen prescription saves nights.
Common questions
- What does a cluster headache attack feel like?
- Excruciating unilateral pain around or behind eye — peaking within minutes, lasting 15 to 180 minutes. Restlessness — pacing, rocking — unlike migraine. Ipsilateral autonomic symptoms — lacrimation, conjunctival injection, rhinorrhoea, miosis/ptosis, forehead sweating. Can occur up to 8 times daily in active cluster period.
- How is cluster headache different from migraine?
- Cluster — shorter attacks (under 3 hours), strictly unilateral orbital, prominent autonomic eye/nose signs, agitation not lying still, male predominance, clock-like regularity including nocturnal timing. Migraine — longer (4–72 hours), throbbing, nausea/vomiting, photophobia, prefers dark quiet room, more common in women.
- How do you treat a cluster headache attack?
- High-flow 100% oxygen 12–15 L/min through non-rebreather mask for 15–20 minutes at attack onset. Subcutaneous sumatriptan 6 mg — fast and effective — max 2 doses daily. Sumatriptan nasal spray alternative. Oral triptans too slow for many. Avoid oxygen if COPD without specialist advice.
- What prevents cluster headache attacks?
- Verapamil — main preventive — ECG monitoring required. Short transitional steroids (prednisolone) bridging until verapamil works. Greater occipital nerve blocks. Galcanezumab (CGRP antibody) for episodic cluster in some cases. Avoid alcohol during cluster period — triggers attacks.
- Can cluster headache be cured?
- No permanent cure — episodic cluster has remission periods between clusters — months to years. Chronic cluster — no remission over a year — harder to treat. Deep brain stimulation or occipital nerve stimulation for refractory chronic cluster in specialist centres.