Synopsis
Recognise the distinctive short, strictly unilateral attacks of cluster headache, provide fast non-oral rescue treatment and coordinate bout prevention with specialist and ECG oversight.
- Cluster headache causes excruciating strictly unilateral orbital, supraorbital or temporal pain lasting 15–180 minutes when untreated, often at a strikingly similar time each day.
- Attacks occur from one every other day up to eight daily and cluster into bouts lasting weeks or months, separated by remission in episodic disease.
- At least one ipsilateral autonomic feature—tearing, conjunctival injection, nasal blockage, rhinorrhoea, eyelid oedema, sweating, miosis or ptosis—or marked restlessness accompanies the pain.
- Patients tend to pace or rock and cannot keep still, unlike many people with migraine who withdraw from movement; this behavioural distinction is diagnostically valuable.
- Offer 100% oxygen at a flow rate of at least 12 litres per minute through a non-rebreathing mask and/or a subcutaneous or nasal triptan for acute attacks.
- Do not offer paracetamol, NSAIDs, opioids, ergots or oral triptans for acute cluster headache because onset is too rapid or the harm-benefit balance is unfavourable.
- When oxygen is prescribed, arrange both stationary and ambulatory equipment where appropriate and ensure a non-rebreathing mask rather than ordinary nasal cannulae.
- Consider verapamil during a cluster bout, seeking specialist advice for dose escalation and ECG monitoring; initial and serial conduction checks are central to safe use.
- Discuss neuroimaging with a clinician experienced in headache for a first bout, and reassess established disease if side, duration, neurology or autonomic findings change.
Key red flags
Ptosis and miosis persisting outside attacks, especially with new neck pain, should prompt urgent assessment for carotid dissection or another sympathetic-pathway lesion.
A persistently red painful eye, reduced acuity, cloudy cornea, fixed pupil or ongoing vomiting is not safely attributed to cluster headache and needs urgent ophthalmic assessment.
Investigation priorities
Demonstrate the stereotyped timing, autonomic accompaniments, triggers, treatment response and bout boundaries.
Management branches
A typical cluster attack begins in a person with a secure diagnosis.
- Use 100% oxygen at at least 12 litres per minute through a reservoir non-rebreathing mask and/or the prescribed subcutaneous or nasal triptan immediately.
- Continue the agreed oxygen session and triptan limits exactly, documenting response time and avoiding repeat doses beyond the formulation maximum.
- If the attack differs in duration, eye findings, neurology or recovery, stop treating by pattern alone and arrange urgent reassessment.
- After repeated rescue use, confirm equipment function, attack frequency and preventive progress rather than substituting oral analgesics or opioids.
Correct rescue fails, verapamil is unsafe, attacks become continuous or the phenotype no longer fits.
- Check oxygen flow and mask, injection or nasal technique, timing, triptan quantity and adherence before declaring pharmacological failure.
- Reclassify attack duration and frequency against paroxysmal hemicrania, SUNCT or SUNA, migraine, neuralgia and structural mimics.
- Arrange headache-neurology review for alternative preventives, nerve block, transitional therapy or advanced options under the commissioned pathway.
Key medicines
High-flow medical oxygenUse 100% oxygen at a flow of at least 12 litres per minute through a reservoir non-rebreathing mask during the attack.Prescribe the correct cylinder, regulator and mask, arrange ambulatory supply when needed, and give strict fire and smoking safety advice; nasal cannulae are inadequate.
Sumatriptan subcutaneousUsually 6 mg at attack onset; a second 6 mg dose may be used for a subsequent attack after at least 1 hour, maximum two doses in 24 hours.Avoid with relevant coronary, cerebrovascular or peripheral arterial disease and uncontrolled hypertension; severe hepatic impairment is contraindicated, and renal or mild-to-moderate hepatic impairment requires product-specific caution. Check interacting triptans or ergots and daily attack burden.