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.
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.
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.
Correct rescue fails, verapamil is unsafe, attacks become continuous or the phenotype no longer fits.
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.
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.