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    Cluster Headache

    Cardinal Presentations / Presenting Problems, Neurological

    Last Updated Dec 15, 2023
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    First 5 Minutes

    • Neither non-opioid nor opioids are effective treatments.
    • High incidence of suicidal ideation and self-injurious behaviour.


    • Very low prevalence <1%.
    • Affects primarily males aged 20-40.
    • Typically attacks are “clustered” and can last between 15 min to 3 hours with periods of remissions in between.
    • Strictly unilateral with ipsilateral cranial autonomic signs.
    • Triggers include alcohol, PDE5 inhibitors, high altitude, weather changes and circadian rhythm disruption.

    Diagnostic Process

    Rule out headache red flags:

    1. rapid onset
    2. thunderclap headaches
    3. neurodeficits
    4. neck pain with/without fever
    5. age > 50
    6. worse with positional changes or Valsalva
    7. new/worsening headaches

    Diagnostic criteria based on the ICHD-3:

    • At least five attacks fulfilling criteria B-D.
    • Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated)1.
    • Either or both of the following:
      • at least one of the following symptoms or signs, ipsilateral to the headache:
        • conjunctival injection and/or lacrimation.
        • nasal congestion and/or rhinorrhoea.
        • eyelid oedema.
        • forehead and facial sweating.
        • miosis and/or ptosis.
        • a sense of restlessness or agitation.
    • Occurring with a frequency between one every other day and 8 per day2.
    • Not better accounted for by another ICHD-3 diagnosis.

    Recommended Treatment

    • First Line Therapy
      • O2 inhalation via non-rebreather face mask at 12-15 L/min for at least 15 min.
      • Sumatriptan 6mg subcutaneous OR 20mg intranasal contralateral to side of pain.
      • Zolmitriptan 10mg oral or intranasal contralateral to side of pain.
    • Second Line Therapy
      • Lidocaine 1mL of 4% solution intranasal ipsilateral to side of pain.
      • Ergotamine 2mg sublingual q30min to a maximum dose of 6mg.
      • Dihydroergotamine 1mg IV bolus q1hr to a maximum of 3mg.
      • Octreotide 100 mcg subcutaneous.

    Criteria For Hospital Admission

    Hospital admission not required.

    Quality Of Evidence?


    Recommendations are based on observational data from a limited number of small studies.


    Related Information


    Reference List

    1. Leone M, May A. Acute treatment of cluster headache attacks. In: Leone M, May A, eds. Cluster Headache and other Trigeminal Cephalgias. 1st ed. Springer; 2020: 131-134. Accessed November 29, 2023.

    2. Leone M, May A. Classification and clinical features. In: Leone M, May A, eds. Cluster Headache and other Trigeminal Cephalgias. 1st ed. Springer; 2020: 11-21. Accessed November 29, 2023.

    3. Lund NLT, Petersen AS, Fronczek R, Tfelt-Hansen J, Belin AC, Meisingset T, et al. Current treatment options for cluster headache: limitations and the unmet need for better and specific treatments – a consensus article. J Headache Pain. 2023;24(1):121. https://doi.org/10.1186/s10194-023-01660-8

    4. Di Sabato F, Giacovazzo M. Management of cluster headache in the emergency department. J Headache Pain. 2005;6(4):294-297.


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