Cluster headache is a primary headache with attacks of extreme, one-sided pain around the eye together with tearing and nasal symptoms on the same side. Attacks come in clusters lasting weeks to months, often at the same time of day, and it is more common in men and smokers.
Key symptoms
- Severe stabbing pain around or behind one eye, lasting 15 to 180 minutes
- Up to 8 attacks a day, often waking the patient at night
- Tearing, red eye, and runny or blocked nose on the same side
- Restlessness and pacing during attacks
What you find on exam
- Drooping eyelid and small pupil on the painful side (Horner signs) during attacks
- Facial sweating or flushing on that side
- Normal neurologic exam between attacks
- Check for fever, neck stiffness and other secondary causes
Tests
- Diagnosis based on clinical criteria
- Brain MRI at first presentation to exclude a structural cause, including the pituitary
- ECG before starting verapamil
Treatment basics
- Acute: 100 percent oxygen at 12 to 15 L per minute by non-rebreather mask for 15 minutes
- Acute: subcutaneous sumatriptan or intranasal zolmitriptan
- Bridge: a short prednisone course or an occipital nerve block
- Prevention: verapamil with ECG monitoring; lithium or galcanezumab as options
- Stop smoking and avoid alcohol during a cluster
Red flags
- New headache after age 50 or with neurologic deficits
- Fever, stiff neck or confusion
- Thoughts of suicide during long clusters
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.