Cluster headache — the suicide headache
Cluster headache belongs to trigeminal autonomic cephalalgias (TACs) — primary headache with severe unilateral pain and ipsilateral autonomic features.
~1/1000 prevalence — 3:1 male — peak 20–40
Nicknamed “suicide headache” — pain intensity unmatched among primary headaches
Attack characteristics
Diagnostic criteria (brief):
- Severe unilateral orbital/temporal/supraorbital pain
- 15–180 minutes duration
- Frequency every other day to 8 daily
- At least one ipsilateral autonomic sign:
- Conjunctival injection
- Lacrimation
- Nasal congestion/rhinorrhoea
- Forehead/facial sweating
- Miosis/ptosis
- Eyelid oedema
Restlessness — key differentiator from migraine
Episodic vs chronic
Episodic cluster:
- Cluster periods — weeks to months
- Remission ≥3 months
Chronic cluster:
- No remission over 12 months
- Harder to treat
Circadian and circannual rhythm — spring/autumn onset common
Triggers
Alcohol — reliable trigger during cluster period only
Nitroglycerin — medical provocation test
Sleep — attacks often 1–2 hours after falling asleep
Strong odours — solvents
Acute treatment
| Treatment | Details |
|---|---|
| Oxygen | 12–15 L/min, non-rebreather, 15 min |
| Sumatriptan SC | 6 mg — onset ~10 min |
| Sumatriptan nasal | 20 mg if needle aversion |
| Zolmitriptan nasal | Alternative |
Avoid:
- Oral triptans alone — too slow
- Oxygen with significant COPD without advice
Prevention
Verapamil:
- Start low, titrate — up to 960 mg/day
- ECG before and during — heart block risk
Bridge:
- Prednisolone taper — rapid cluster control short term
Other:
- Lithium
- Topiramate
- Greater occipital nerve block
- Galcanezumab — episodic cluster
Secondary causes — must exclude
MRI brain with attention to pituitary and cavernous sinus
Red flags for secondary:
- Atypical autonomic pattern
- Abnormal examination between attacks
- Older age first onset
Living with cluster
Headache diary — timing proves cluster pattern
Workplace adjustments — predictable sick leave during cluster
OUCH UK peer support
Suicidal ideation during attacks common — crisis plan
Waking same time nightly with eye pain and tears — not sinusitis until proven — GP + neurology — oxygen prescription saves nights.
Common questions about cluster headache
- What does a cluster headache attack feel like?
- Excruciating unilateral pain around or behind eye — peaking within minutes, lasting 15 to 180 minutes. Restlessness — pacing, rocking — unlike migraine. Ipsilateral autonomic symptoms — lacrimation, conjunctival injection, rhinorrhoea, miosis/ptosis, forehead sweating. Can occur up to 8 times daily in active cluster period.
- How is cluster headache different from migraine?
- Cluster — shorter attacks (under 3 hours), strictly unilateral orbital, prominent autonomic eye/nose signs, agitation not lying still, male predominance, clock-like regularity including nocturnal timing. Migraine — longer (4–72 hours), throbbing, nausea/vomiting, photophobia, prefers dark quiet room, more common in women.
- How do you treat a cluster headache attack?
- High-flow 100% oxygen 12–15 L/min through non-rebreather mask for 15–20 minutes at attack onset. Subcutaneous sumatriptan 6 mg — fast and effective — max 2 doses daily. Sumatriptan nasal spray alternative. Oral triptans too slow for many. Avoid oxygen if COPD without specialist advice.
- What prevents cluster headache attacks?
- Verapamil — main preventive — ECG monitoring required. Short transitional steroids (prednisolone) bridging until verapamil works. Greater occipital nerve blocks. Galcanezumab (CGRP antibody) for episodic cluster in some cases. Avoid alcohol during cluster period — triggers attacks.
- Can cluster headache be cured?
- No permanent cure — episodic cluster has remission periods between clusters — months to years. Chronic cluster — no remission over a year — harder to treat. Deep brain stimulation or occipital nerve stimulation for refractory chronic cluster in specialist centres.