Cluster headache


  • Occur most often in middle aged men
  • Classically occur in "clusters" over days to weeks typically at the same time of day and same anatomical location.
  • Triggers may be alcohol, nitroglycerin, histamine


At least 5 attacks of headache fulfilling the following criteria:

  1. Severe unilateral orbital, supraorbital, or temporal pain lasting 15–180 min if untreated
  2. Headache accompanied by at least one of the following:
    • Ipsilateral conjunctival injection and/or lacrimation
    • Ipsilateral nasal congestion and/or rhinorrhea
    • Ipsilateral eyelid edema
    • Ipsilateral forehead and facial sweating
    • Ipsilateral miosis and/or ptosis
    • A sense of restlessness or agitation
  3. Attacks have a frequency from one every other day to eight per day
  4. Not attributed to another disorder

Differential Diagnosis






Aseptic Meningitis


  • Consider other emergent causes of headache based on H&P
    • Consider CT, LP, and/or eye pathology
  • Typically a clinical diagnosis


  • High-flow O2 (effective in 70% of patients)[2]
  • Intranasal lidocaine 4%
  • DHE
  • Sumatriptan
  • Intranasal zolmitriptan
  • Subcutaneous or IM dihydroergotamine and intranasal sumatriptan are additional options
  • Verapamil can be used for prophylaxis
  • Prednisone taper with verapamil has shown to reduce frequency of attacks[3]


  • Normally outpatient

See Also


  1. International Headache Society Diagnostic Criteria
  2. Headache. 2013 Jul-Aug;53(7):1191-6. doi: 10.1111/head.12145. Epub 2013 Jun 14. Cluster headache: conventional pharmacological management. Becker WJ1.
  3. Obermann M, Nägel S, Ose C, et al. Safety and efficacy of prednisone versus placebo in short-term prevention of episodic cluster headache: a multicentre, double-blind, randomised controlled trial. Lancet Neurol. 2021;20(1):29-37. doi:10.1016/S1474-4422(20)30363-X