Cluster headaches are known to be one of the most painful conditions that patients can have the misfortune to suffer. The name relates to the pattern of the headaches - they typically occur in clusters lasting several weeks, with the clusters themselves typically once a year.

Cluster headaches are more common in men (3:1) and smokers. Alcohol may trigger an attack and there also appears to be a relation to nocturnal sleep.

Features

• intense sharp, stabbing pain around one eye
• pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
• the patient is restless and agitated during an attack due to the severity
• clusters typically last 4-12 weeks
• accompanied by redness, lacrimation, lid swelling
• nasal stuffiness
• miosis and ptosis in a minority

Investigations

• most patients will have neuroimaging - underlying brain lesions are sometimes found even if the clinical symptoms are typical for cluster headache
• MRI with gadolinium contrast is the investigation of choice

Management

• NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches
• acute
  • 100% oxygen (80% response rate within 15 minutes)
  • subcutaneous triptan (75% response rate within 15 minutes)
• prophylaxis
  • verapamil is the drug of choice
  • there is also some evidence to support a tapering dose of prednisolone

Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). It is recommended such patients are referred for specialist assessment as specific treatment may be required, for example it is known paroxysmal hemicrania responds very well to indomethacin