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
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.
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