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.

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.

Cluster headache: Symptoms & 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 about cluster headache

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.

Sources

How we reviewed this page

Medically reviewed by the HealthAnswers UK doctor review panel

First published: 14 June 2026
Medically reviewed: 3 July 2026
Next review due: 3 July 2029 or sooner if NHS or NICE guidance changes

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