Cluster Headache

Cluster headache is a rare primary headache disorder, which is not associated with another underlying condition. Cluster headache attacks occur in series usually lasting between 2 weeks and 3 months (cluster periods or 'bouts').

Cluster headache attacks are typified by severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15 minutes to 3 hours (untreated) with:

• At least one of the following ipsilateral symptoms or signs: conjunctival injection and/or lacrimation; nasal congestion and/or rhinorrhoea; eyelid swelling; forehead and facial sweating or flushing; sensation of fullness in the ear; miosis (excessive pupillary constriction) and/or ptosis.
• A sense of restlessness or agitation.

Smoking and alcohol may be trigger factors for cluster headache and patients should be given advice on reducing alcohol intake and smoking cessation as appropriate.

All patients should be advised on the risk of medication-overuse headache and overuse of acute medicines should be addressed. 

There is no evidence to support the use of opioids, NSAIDs, paracetamol or oral triptans in the management of confirmed cluster headache.

A management plan will typically be in discussion with the neurologist.

Management of an acute attack in a patient with known cluster headache

• Sumatriptan 6mg subcutaneous injection is first line
  • Dose: A single 6 mg subcutaneous injection for each cluster attack.
  • The maximum dose in 24 hours is two 6 mg injections (12 mg) with a minimum interval of one hour between the two doses.

• Sumatriptan nasal spray for those who can't tolerate injection
  • Dose: Initially 10–20 mg administered into one nostril.
  • If there is no response to the first dose, a second dose should not be taken for the same attack.
  • If headache recurs a second 10-20mg dose can be administered.
  • This should not be taken within 2 hours of the initial dose.
  • Maximum dose in 24 hours is 40mg.

• Short burst oxygen therapy (100% oxygen)
  • 100% oxygen at a rate of 10-15 litres/minute for 10–20 minutes is useful in aborting an attack.
  • Oxygen treatment is initiated by a Consultant Neurologist.

Preventative treatment

Prophylaxis with verapamil may be suggested by the specialist. It is typically used just during the bout of headaches rather than all the time. It is established first line preventative treatment but unlicensed for this indication.

Cluster headache is rare and debilitating and it is reasonable to refer all patients to confirm the diagnosis.

Refer patients with established diagnosis not responding to treatment for consideration of Oxygen or nerve blocks.

Refer via SCI-Gateway...DGRI...Neurology

Patients with established cluster headache who are responding to treatment.