Cluster headache

Last updated: August 10, 2020

Summarytoggle arrow icon

Cluster headache (CH) is a type of primary headache that mostly affects adult men. Patients present with recurrent, fifteen minute up to three hour attacks of agonizing, strictly unilateral headaches in the periorbital and forehead region (areas innervated by the trigeminal nerve). These attacks are associated with ipsilateral symptoms of increased cranial autonomic activity, e.g., lacrimation, conjunctival injection, rhinorrhea, or partial Horner syndrome. Cluster headaches tend to occur in episodic patterns (“cluster bouts”) followed by months of remission, but are considered chronic if remission between bouts lasts less than one month. Diagnosis is based on the patient's history, in particular on the exact description and timing of the headaches. Acute episodes are treated with 100% oxygen or triptans, while verapamil is used for preventative treatment.


Epidemiological data refers to the US, unless otherwise specified.


  • Headache characteristics
    • Agonizing pain
    • Strictly unilateral, periorbital, and/or temporal
    • Short, recurring attacks; that usually occur in a cyclical pattern (“clusters”)
      • May become chronic (less common), with interruptions of less than one month between cluster bouts
      • Attacks often wake patients up during sleep.
  • Ipsilateral autonomic symptoms
  • Restlessness and agitation

While patients with migraine headaches tend to rest motionlessly in a quiet, dark room, individuals with cluster headache pace around restlessly in excruciating pain!




The differential diagnoses listed here are not exhaustive.

Medical therapy

Interventional therapy

Interventional procedures (e.g., ablative injections, deep brain stimulation) may be considered in patients with cluster headache who do not respond to medical therapy.


Apply nasal sprays in the nostril that is not affected by congestion to improve absorption (except lidocaine, which acts locally).
Ergotamines and triptans should not be taken within 24 hours of one another because of the risk of coronary artery spasms.

Ischemic vascular disease, accessory conduction pathway disorders, and pregnancy are important contraindications for triptans and ergotamines.

  1. The International Classification of Headache Disorders 3rd Edition. Updated: January 1, 2016. Accessed: April 2, 2017.
  2. Blanda M. Cluster Headache. In: Ramachandran TS, Cluster Headache. New York, NY: WebMD. Updated: January 12, 2017. Accessed: November 19, 2017.
  3. Lodi R, Pierangeli G, Tonon C, et al. Study of hypothalamic metabolism in cluster headache by proton MR spectroscopy. Neurology. 2006; 66 (8): p.1264-1266. doi: 10.1212/01.wnl.0000208442.07548.71 . | Open in Read by QxMD
  4. Clinical Reasoning: Partial Horner syndrome and upper right limb symptoms following chiropractic manipulation. Updated: May 26, 2015. Accessed: April 2, 2017.
  5. Matharu M. Cluster Headache. BMJ Clin Evid. 2010; 2010 (1212).
  6. Mendizabal JE, Umaña E, Zweifler RM. Cluster headache: Horton's cephalalgia revisited. South Med J. 1998; 91 (7): p.606-617.
  7. Weintraub JR. Cluster headaches and sleep disorders. Curr Pain Headache Rep. 2003; 7 (2): p.150-156.
  8. Cittadini E, Matharu MS, Goadsby PJ. Paroxysmal hemicrania: a prospective clinical study of 31 cases. Brain. 2008; 131 (4): p.1142-1155. doi: 10.1093/brain/awn010 . | Open in Read by QxMD
  9. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38 (1): p.1-211. doi: 10.1177/0333102417738202 . | Open in Read by QxMD
  10. Singh MK. Chronic Paroxysmal Hemicrania. Chronic Paroxysmal Hemicrania. New York, NY: WebMD. Updated: December 8, 2014. Accessed: April 2, 2017.
  11. Alternatives in drug treatment of chronic paroxysmal hemicrania. Updated: July 1, 1996. Accessed: April 2, 2017.
  12. Short-Lasting Unilateral Neuralgiform Headache With Conjunctival Injection and Tearing (SUNCT). Updated: April 1, 2020. Accessed: May 12, 2020.
  13. Pareja JA, Álvarez M, Montojo T. SUNCT and SUNA: Recognition and Treatment. Curr Treat Options Neurol. 2012; 15 (1): p.28-39. doi: 10.1007/s11940-012-0211-8 . | Open in Read by QxMD
  14. International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33 (9): p.629-808. doi: 10.1177/0333102413485658 . | Open in Read by QxMD
  15. Cluster Headache. Updated: April 1, 2017. Accessed: April 2, 2017.
  16. Headaches: Diagnosis and Management of Headaches in Young People and Adults. Updated: July 1, 2012. Accessed: November 19, 2017.
  17. Beck E, Sieber WJ, Trejo R. Management of cluster headache.. Am Fam Physician. 2005; 71 (4): p.717-24.
  18. Wei DY, Khalil M, Goadsby PJ. Managing cluster headache. Pract Neurol. 2019; 19 (6): p.521-528. doi: 10.1136/practneurol-2018-002124 . | Open in Read by QxMD
  19. Burish MJ. Cluster Headache: History, Mechanisms, and Most Importantly, Treatment Options. Practical Neurology. 2017 : p.34-36.
  20. Robbins MS, Starling AJ, Pringsheim TM, Becker WJ, Schwedt TJ. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache. 2016; 56 (7): p.1093-1106. doi: 10.1111/head.12866 . | Open in Read by QxMD
  21. Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology. 2010; 75 (5): p.463-473. doi: 10.1212/wnl.0b013e3181eb58c8 . | Open in Read by QxMD
  22. May A. Cluster headache: pathogenesis, diagnosis, and management. Lancet. 2005; 366 (9488): p.843-855. doi: 10.1016/s0140-6736(05)67217-0 . | Open in Read by QxMD
  23. Mazzoni P, Pearson T, Rowland LP. Merritt's Neurology Handbook. Lippincott Williams & Wilkins ; 2006
  24. Cluster Headache. Updated: January 1, 2017. Accessed: April 2, 2017.
  25. Blanda M. Cluster Headache: Treatment & Management. Cluster Headache: Treatment & Management. New York, NY: WebMD. Updated: January 12, 2017. Accessed: April 2, 2017.
  26. Goadsby PJ. Pathophysiology of cluster headache: a trigeminal autonomic cephalgia. Lancet Neurol. 2002; 1 (4): p.251-257.
  27. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
  28. Matharu MS, Levy MJ, Meeran K, Goadsby PJ. Subcutaneous octreotide in cluster headache: Randomized placebo-controlled double-blind crossover study. Ann Neurol. 2004; 56 (4): p.488-494. doi: 10.1002/ana.20210 . | Open in Read by QxMD
  29. Ferri FF. Ferri's Clinical Advisor 2015 E-Book. Elsevier Health Sciences ; 2014
  30. May A, Schwedt TJ, Magis D, Pozo-Rosich P, Evers S, Wang S-J. Cluster headache. Nat Rev Dis Primers. 2018; 4 (1). doi: 10.1038/nrdp.2018.6 . | Open in Read by QxMD
  31. Levine H. Headache in Otolaryngology: Rhinogenic and Beyond, An Issue of Otolaryngologic Clinics of North America,. Elsevier Health Sciences ; 2014
  32. Brandt RB, Doesborg PGG, Haan J, Ferrari MD, Fronczek R. Pharmacotherapy for Cluster Headache. CNS Drugs. 2020; 34 (2): p.171-184. doi: 10.1007/s40263-019-00696-2 . | Open in Read by QxMD
  33. Goadsby PJ, Dodick DW, Leone M, et al. Trial of Galcanezumab in Prevention of Episodic Cluster Headache. N Engl J Med. 2019; 381 (2): p.132-141. doi: 10.1056/nejmoa1813440 . | Open in Read by QxMD
  34. Paemeleire K, Evers S, Goadsby PJ. Medication-overuse headache in patients with cluster headache. Curr Pain Headache Rep. 2008; 12 (2): p.122-127. doi: 10.1007/s11916-008-0023-4 . | Open in Read by QxMD
  35. Costa A, Antonaci F, Ramusino M, Nappi G. The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias. Curr Neuropharmacol. 2015; 13 (3): p.304-323. doi: 10.2174/1570159x13666150309233556 . | Open in Read by QxMD
  36. Ferrari A, Zappaterra M, Righi F, et al. Impact of continuing or quitting smoking on episodic cluster headache: a pilot survey. J Headache Pain. 2013; 14 (1). doi: 10.1186/1129-2377-14-48 . | Open in Read by QxMD

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer