Cluster headache


  • M:F = 3:1, Early adulthood
  • Cause unknown, may be familial
  • Rarely presents 1st episode (consider SAH) as must >5 episodes to Dx (see below)


  • Unilateral headache onset on waking or early hours
  • Sudden onset / offset, excruciating darting pain
  • Short-lasting headaches (10 min - 2 hours)
  • No aura or neurological symptoms
  • Nausea/vomiting are rare
  • Accompanied by facial parasympathetic dysfunction.
    • Ipsilateral lacrimation / rhinorrhoea
    • Swollen eyelid/nose /face ± conjunctival injection
    • Partial Horner's synd. may persist after the headache



  • If MRI required (atypical ppt or persisting autonomic features), please ensure vasculature is also imaged (MRA MRV)


  • High flow Oxygen (admit CDU - non-rebreather mask)
  • ± subcutaneous/nasal triptan
  • Do NOT offer paracetamol, NSAIDS, opioids for the acute treatment of cluster headache
  • Consider high dose (100mg prednisolone) steroids (only acutely) in persistent cases
  • Prophylaxis: consider verapamil (min. daily dose 240mg)
  • Neurologist (not EM) may consider prophylactic lithium, topiramate or galcanezumab

Content by Dr Íomhar O' Sullivan . Last review Dr ÍOS 2/11/23.