Cluster Headaches

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What are cluster headaches?

Cluster headaches, named for the cyclical patterns or clusters of frequent headaches, are the most painful type of headache. Patients describe them as “burning,” “a hot poker in the eye,” “stabbing pain,” or a “suicide headache.” They are the most common type of headache disorders called trigeminal autonomic cephalalgias. There may be as many as one million Americans with this condition.

Cluster headaches usually awaken you from sleep with intense pain around one eye on one side of the head. Bouts of frequent headaches are called cluster periods, and last weeks or months. During a cluster period, you may have several headaches a day or one every other day. Headaches stop during the remission periods, and remission can last for months to years. 

Of unknown cause, cluster headaches are not life-threatening. Treatment can make the headaches shorter, less severe and reduce the number of cluster headaches.

Causes

What causes cluster headaches?

The exact cause of cluster headaches is unknown. They may be linked to the sudden release of histamine or serotonin in the body. The patterns of cluster headaches suggest that changes or disruptions in the body's biological clock (hypothalamus) play a role. Unlike migraine and tension headaches, cluster headaches aren’t triggered by foods, stress or hormonal changes. However, while you’re in a cluster period, certain things can quickly trigger a splitting headache. Triggering behaviors can include drinking alcohol, smoking tobacco, taking nitroglycerine (treats heart disease), bright light, exercise or exertion, high altitude, eating foods that contain nitrates (procession lunch meat or bacon), becoming overheated from bathing or the weather, and cocaine use. 

Who’s at risk for cluster headaches?

You’re more likely to have cluster headaches if you are:

  • Male, although this is changing as more women are getting cluster headaches
  • Between the ages of 20 through your 40s, but it can develop at any age
  • A smoker, although quitting smoking doesn’t affect the headaches
  • Member of a family with cluster headaches, although not all members are affected
  • Not getting regular sleep or changing your normal sleep schedule can trigger a cluster period

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Symptoms

What are the symptoms of cluster headaches?

Extreme pain in and around one eye with head pain on the same side as eye pain, lasting one to three hours

Pain strikes quickly, without warning, although some people have migraine-like nausea and aura just before it strikes

Pain peaks in about 15 minutes

Pain may radiate to your face, head and neck

Excessive tearing or a red, watery eye on the affected side

Swelling around your eye or drooping eyelid on the affected side

Stuffy or runny nose on the affected side

Facial sweating on the affected side

Restlessness and the inability to be still or lie down

Pacing or rocking in one place

Banging the head to distract from the pain

Pale skin or face flushing

Exhaustion after the sudden end of the headache

Cluster periods can last from ‌weeks‌ ‌to‌ ‌months. The intervening remission periods without headaches can last from months to years. Some people have cluster headaches at the same time every year, although they may skip years. If you have chronic cluster headaches, there are no remission periods, or remission lasts less than a month. 

During a cluster period, these symptoms are usually present:

One to several headaches a day

Headaches last from 15 minutes to three hours

Attacks occur at the same time each day; often of the same duration

Attacks usually occur one to two hours after you go to bed

Cluster headaches are not life-threatening. However, get immediate emergency medical attention if you have an abrupt, severe headache; headache with fever, nausea or vomiting, stiff neck, mental confusion, seizures, numbness, or speaking difficulties; headache after any head injury or fall, especially if it worsens; or a worsening headache that changes in pattern.

Diagnosis

How are cluster headaches diagnosed?

Diagnosis starts by describing symptoms to your doctor, including how long the headaches last, any patterns of when they occur, and the pain’s severity. It’s extremely helpful to keep a headache diary noting the date (to help establish patterns), length, intensity, and if you have any pre-headache signs such as an aura. Share this information about each attack with your doctor. 

Cluster headaches are often misdiagnosed as migraine headaches. Because there’s been less research on cluster headaches, many doctors try to treat cluster headaches with medications that help migraines. These are two very different headache conditions, and migraine treatment will not provide successful cluster headache treatment. Treatment must be based on an accurate diagnosis of cluster headache. Misdiagnosis can delay a correct diagnosis for years. 

Patients should be evaluated for other headache conditions with symptoms similar to cluster headaches. Your doctor may use these diagnostic methods: 

Neurological exam can detect any physical signs of a neurological disorder, by testing your reflexes, nerves and senses. 

Imaging tests (an MRI or CT scan) produce detailed pictures of your brain and blood vessels.

Treatment

What are the treatment options for cluster headaches?

While there is no cure for cluster headaches, treatment focuses on stopping/reducing headache pain, shortening the cluster periods, and preventing future attacks. An individual treatment plan should include a temporary form of initial relief with steroids, a daily preventive medication, and a way to provide immediate treatment relief for an ongoing attack.

Pain relief needs to be fast-acting because cluster headaches start and stop abruptly. For that reason, oral medications (such as opioids for pain relief), which are relatively slow to act, are too slow to provide acute treatment for cluster headaches. 

Treatments may include:

High-dose pure oxygen through a face mask for 15 to 20 minutes can stop or lessen an attack in progress, often within 15 minutes. Oxygen has no side effects, but patients need to have ready access to an oxygen cylinder and regulator. Small, portable oxygen units are available but may be impractical for many patients.

Sumatriptan (Imitrex) nasal spray can constrict blood vessels in the brain, which relieves pain. The injectable form of sumatriptan (also used to treat migraine) is more effective and works quicker for most people. People with heart disease or uncontrolled high blood pressure should not take sumatriptan.

Zolmitriptan (Zomig) has an effect similar to sumatriptan and is available in nasal spray for fast-acting treatment.

Octreotide (Sandostatin), an injectable synthetic version of the brain hormone somatostatin, helps some patients. It’s slower-acting and less effective than sumatriptan.

Local anesthetics, such as lidocaine, can help numb the pain with a nerve block. It’s given for temporary relief by injection through the nose; may be used with corticosteroids and/or verapamil.

Dihydroergotamine as an injection, helps relieve pain for some patients. 

Daily medications can help prevent future headaches. You may be prescribed:

-Verapamil is a calcium channel blocker that relaxes blood vessels. Side effects can include constipation, nausea, fatigue, swelling of the ankles, and low blood pressure.

-Prednisone is a corticosteroid that reduces inflammation and swelling for a few days. Not advised for long-term use because it can cause diabetes, high blood pressure, and cataracts.

-Lithium carbonate restores balance to brain chemicals, and may be used if other medications aren’t preventing headaches. Side effects include tremor, increased thirst and diarrhea. Patients on lithium must have regular blood tests to check for kidney damage.

Vagus nerve stimulation, which delivers electrical stimulation to the vagus nerve through the skin, has been found to reduce the frequency of cluster headaches. 

Anti-seizure medications (Topamax, Qudexy XR) are sometimes used to prevent cluster headaches.

Surgery may be done on patients who cannot take medications or who have chronic cluster headaches that don’t respond to aggressive treatments. 

Sphenopalatine ganglion stimulation involves surgery to implant a neurostimulator that's operated by a hand-held controller. Initial research showed quick pain relief and a lower frequency of headaches.

-Occipital nerve stimulation involves surgery to implant an electrode next to one or both occipital nerves.

References

Mayo Clinic. (2021, July). Cluster Headache. Retrieved 1-17-22, {https://www.mayoclinic.org/diseases-conditions/cluster-headache/symptoms-causes/syc-20352080#:~:text=Cluster%20headaches%2C%20which%20occur%20in,one%20side%20of%20your%20head.}
Mayo Clinic. (2021, July). Cluster Headache Diagnosis and Treatment. Retrieved 1-17-22, {https://www.mayoclinic.org/diseases-conditions/cluster-headache/diagnosis-treatment/drc-20352084}
Johns Hopkins Medicine. (N.d.) Cluster Headaches. Retrieved 1-17-22, {https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/cluster-headaches}
American Migraine Foundation. (2019, April) Understanding Cluster Headache. Retrieved 1-17-22, {https://americanmigrainefoundation.org/resource-library/cluster-headache-2/}

Information

Medically reviewed by:

Dr. Desiree Levyim

Dr. Desiree Levyim is a board eligible neurologist in practice since 2020. She joins TeleMed2U in our mission to provide increased access to healthcare.

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Initial Visit

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