FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Headache & facial pain

Cluster headache

Trigeminal autonomic cephalalgia

Overview

The most severe primary headache — strictly unilateral, excruciating periorbital pain in clusters (attacks daily for weeks, then remission), with ipsilateral cranial autonomic features and a RESTLESS, agitated patient (unlike migraine where they lie still).

Recognise

  • Severe unilateral periorbital/temporal pain, 15 min–2 hours, often nocturnal/same time daily
  • Ipsilateral autonomic features: lacrimation, conjunctival injection, rhinorrhoea, ptosis/miosis (partial Horner)
  • RESTLESS/agitated during attacks; clusters over weeks then months of remission; M>F, smokers

Red flags

  • First presentation needs imaging to exclude a secondary cause; very high pain/suicidality risk in clusters

Differentials & how to tell them apart

Migrainepatient lies still in a dark room (cluster patients are restless); longer attacks, aura, photophobia
Trigeminal neuralgiabrief electric-shock pains triggered by touch, no autonomic features
Paroxysmal hemicraniashorter, more frequent attacks, ABSOLUTE response to indometacin
Temporal arteritisolder, tender temporal artery, raised ESR, jaw claudication

Investigations

Clinical; MRI head with gadolinium (first presentation, to exclude secondary causes).

Management

Acute: high-flow 100% oxygen + subcut sumatriptan; prophylaxis: verapamil

  1. 1Acute attack: 100% high-flow oxygen via non-rebreathe + subcutaneous or nasal triptan (sumatriptan). Oral triptans/analgesics are too slow.Gate: Use SUBCUTANEOUS/nasal triptan, not oral — attacks peak too fast for an oral drug; and oxygen is specifically effective in cluster (not migraine)
  2. 2Prophylaxis: verapamil (ECG monitoring); a tapering prednisolone course can break a cluster. Refer to neurology.
High-flow 100% oxygen + subcut/nasal triptan — acute attack (sumatriptan SC)
Verapamil — prophylaxis first-line
Short course of prednisolone — to break a cluster (bridging)

Key points

Restless patient + autonomic features + strict unilaterality = cluster (migraine patients lie still). Oxygen + SC triptan is the acute combination; verapamil prevents.

Monitor & prognosis

Attack frequency, verapamil ECG (PR interval), oxygen access.

Episodic clusters with remissions; chronic in a minority.

Source: NICE CKS Cluster headache; NICE NG (headaches)