GPAtlas🧭 When to suspect
Cluster headache is a trigeminal autonomic cephalalgia and one of the most severe pains in medicine. Suspect it when a patient describes attacks of strictly unilateral, excruciating pain in the orbital, supraorbital or temporal region, lasting 15–180 minutes untreated and recurring from once every other day to 8 times a day. The pain is typically boring, stabbing or burning and peaks within minutes.
Two features make the diagnosis. First, ipsilateral autonomic activation – a red, watering eye, a blocked or running nostril, eyelid swelling, drooping or a small pupil on the same side as the pain. Second, restlessness: unlike migraine, where people lie still, the patient with cluster headache paces, rocks and cannot keep still. Attacks often strike at the same time each day, frequently waking the patient from sleep.
The key primary-care skills are to recognise the pattern, treat attacks fast, and exclude a secondary cause at the first presentation.
| Feature | Typical of cluster headache |
|---|---|
| Site | Strictly unilateral; orbital, supraorbital and/or temporal |
| Severity | Severe to very severe – “excruciating” |
| Duration | 15–180 minutes when untreated |
| Frequency | 1 every other day up to 8 per day |
| Autonomic features (ipsilateral) | Lacrimation, conjunctival injection, nasal congestion/rhinorrhoea, eyelid oedema, ptosis/miosis, facial sweating |
| Behaviour | Restless and agitated – paces, cannot lie still |
| Periodicity | Circadian (often nocturnal, same time daily) and seasonal bouts |
Classify by pattern: episodic cluster headache (bouts of 7 days to 1 year separated by pain-free remissions of ≥ 3 months) accounts for most cases, while chronic cluster headache (no remission, or remission < 3 months, for ≥ 1 year) affects around 10–15%.
Source: NICE CG150 · ICHD-3
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