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GPs go forth

Non-Covid clinical crises: Cluster headaches

Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available

Cluster headaches are frequently misdiagnosed and inadequately managed.

The key is to ask patients what they do during an attack. Migraine suffers will want to lie quietly in a darkened room but a patient with cluster headache will be agitated, rock back and forth, and pace the room. 

Important differences between migraine and cluster headache

MigraineCluster headache 

Pain can occur in any location. One or two sites.

Pain is periorbital and unilateral.

Pain is severe and throbbing. Patients want to lie down.

Pain is very severe and piercing. Patients pace the room.

Attack lasts 4-72 hours

 

Attack lasts 15-180 minutes and comes in clusters.

No autonomic features (except rarely).

Autonomic features around the eye on side of pain.

Nausea, vomiting, photophobia or phonophobia.

Absent

 

Ideally, brain MRI is good practice for new cases due to the possibility of pituitary tumour albeit rare. If there are clinically signs of pituitary dysfunction then refer under two week wait.

The treatment of choice is injectable sumatriptan which can be used twice a day over long periods without problems or side-effects. Nasal Triptans may help but oral triptans are ineffective.

If possible, 100% oxygen is a useful adjunct but may not be currently available.

Steroids can be useful to bring things under control quickly. Start with prednisolone 1mg/kg to a maximum of 60mg for three days and reduce over four weeks. A useful approach is to start with steroids and use injectable sumatriptan when needed for breakthrough cluster. High dose verapamil is the best option for chronic cluster headaches (10% of cases) but close monitoring will be required of above licensed doses. (See exeterheadacheclinic.org for further information).

Dr David Kernick is a GP with special interest in headache based in Exeter

Readers' comments (3)

  • Nice summary with concise, useful info thanks

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  • If Cluster Headache responds to Steroids, how is it related to PMR/GCA?

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  • anonymouse3 @7.28am.

    Cluster headache is not related to PMR/GCA which are vasculitic. Steroids can be dramatically effective in CH but shouldn't be used long term. Don't forget a baseline ECG if you are going to start verapamil, and watch BP/pulse.

    Re pituitary tumors- the visual field exam is your friend (remember the bi-temporal hemianopia? Focus on finding the field restricted more so in the upper halves). You would be hard-pressed to find a neurologist who would not arrange a brain MR despite a normal CNS exam and a good history for CH. This is in part due to hypothalamic lesions not always being readily detectable on exam; lesions here can cause CH and dysfunction here in part explains the periodicity of the symptoms.

    Good to see Pulse addressing some "proper medicine"!!

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