EMed

Cluster headache

Background

  • 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)

Clinical

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

DDx

Investigations

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

Management

  • High flow Oxygen (admit CDU - non-rebreather mask)
  • ± subcutaneous/nasal triptan
  • Do NOT offer paracetamol, NSAIDS or opioids
  • Consider 100mg prednisolone (only acutely) if persistent

Prophylaxis:

  • Avoidance of alcohol
  • 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 14/04/24.