Cluster headache

What is cluster headache?

Cluster headache is a trigeminoautonomic headache: severe unilateral pain is accompanied by autonomic symptoms on the same side of the head. Attacks often show diurnal regularity (often at night) and seasonal frequency (e.g. in spring/autumn). Men are affected more often than women, with typical onset between the ages of 20 and 40.

• Pain location: orbital, supraorbital, temporal – strictly unilateral
• Intensity: very strong, drilling/burning
• Accompanying signs: tearing, red conjunctiva, stuffy/runny nose, eyelid edema, forehead/facial sweat, miosis/ptosis
• Behavior: inner restlessness, urge to move (in contrast to migraines)

Anatomy and mechanisms

The pain is transmitted via the first branch of the trigeminal nerve (V1). The accompanying vegetative signs arise via reflex arcs between trigeminal nuclei and parasympathetic centers (facial nerve, sphenopalatine ganglion). Functional imaging shows hypothalamic involvement – ​​consistent with circadian/seasonal patterns. Disturbance of the sympathetic system can cause signs of Horner syndrome (narrow pupil, drooping upper eyelid).

Typical symptoms

• Severe, one-sided eye/temple pain
• Duration per attack: 15-180 minutes
• Frequency: every other day up to 8 attacks/day
• Tearing, reddened conjunctiva, stuffy/runny nose, eyelid edema
• Forehead/facial sweat, ear fullness, miosis/ptosis
• Severe restlessness, interrupted sleep (especially at night)

Between attacks, many of those affected are symptom-free, unless the form is chronic.

Forms: episodic and chronic

A distinction is made between episodic and chronic cluster headaches. Both meet the same attack criteria, but differ in the attack-free interval.

• Episodic: cluster phases lasting weeks to months with remissions lasting at least 3 months.
• Chronic: Attacks without remission or with remissions < 3 months over at least 1 year.

Causes and triggers

The exact cause is not completely clear. Evidence suggests a disorder in the hypothalamus and overactivity of trigeminal pain pathways. Genetic factors appear to be involved; Environmental factors influence attacks.

• Triggers during an active cluster phase: alcohol, nitroglycerin, strong smells (solvents, smoke), foods rich in histamine or tyramine
• Lack of sleep or irregular sleep-wake rhythm
• Weather changes/barometer changes (individual differences)

Diagnostics: clinical, targeted, safe

The diagnosis is based on the International Classification of Headache Disorders (ICHD-3) criteria. The decisive factors are the character of the seizure, accompanying symptoms and strict one-sidedness. A thorough anamnesis and physical-neurological examination are crucial.

• Recording of frequency, duration, time of day, triggers, accompanying signs
• Headache diary for monitoring progress
• Neurological status; Eye/nose inspection
• Imaging (MRI of the head) for atypical features, late onset, neurological abnormalities or resistance to therapy for exclusion diagnosis

Warning signs (e.g. sudden severe headache, fever/stiff neck, new neurological deficits, red eyes with loss of vision) require immediate emergency evaluation.

Differential diagnoses

• Migraine (often nausea/photophobia, need to rest; less vegetative facial symptoms)
• Hemicrania continua / Paroxysmal hemicrania (indomethacin-sensitive)
• Trigeminal neuralgia (electronic bursts of pain lasting seconds, trigger zones)
• Occipital neuralgia (stinging pain in the back of the head, tender nerve points)
• Secondary causes: sinusitis, eye disease (glaucoma), carotid dissection, mass

Acute treatment of the attack

The goal is quick relief. Oral painkillers usually work too slowly. Evidence-based acute options are prescribed by a doctor and tailored to the individual.

• 100% oxygen via mask (e.g. 12-15 l/min via non-rebreather mask) early at the start of the attack; good tolerance.
• Triptans: sumatriptan s.c. or intranasally, zolmitriptan intranasally (careful consideration if there are cardiovascular risks).
• Intranasal lidocaine as an option in individual cases.
• Cooling/Local Measures: Some benefit from cold packs on the affected side.

Important: Dosage and contraindications are checked by a doctor. Emergency medication should be available, especially for nocturnal attacks.

Bridging therapy (Transitional Therapy)

Bridging devices are used at the beginning of a cluster phase until prophylaxis takes effect.

• Corticosteroids (e.g. prednisolone short-term, tapered) - limited due to side effects.
• Injection/blockade of the greater occipital nerve (occipital nerve block) may temporarily reduce attack frequency.

Prophylaxis: Prevent attacks

Prophylactics are titrated individually and monitored by a doctor. The aim is to reduce the frequency and severity of attacks.

• Verapamil: first choice agent; requires ECG monitoring during dose escalation.
• Lithium: option v. a. with a chronic course; Regular blood level and organ function checks are necessary.
• Topiramate or melatonin: alternatives in selected cases.
• Occipital nerve block repeated as a supplementary measure.

Monoclonal antibodies against CGRP/CGRP receptor are approved for migraine; The use for cluster headaches is currently restricted or off-label in Europe and should only be used after careful consideration by headache specialists.

Interventional procedures for treatment-resistant disease

If medication strategies do not help sufficiently, specialized procedures, usually offered in inpatient settings or in headache centers, can be considered. These decisions must be made individually and on an interdisciplinary basis.

• Sphenopalatine ganglion (SPG) blockages; in selected cases SPG stimulation.
• Occipital nerve stimulation (ONS) for chronic, refractory cluster headache.
• Deep brain stimulation of the posterior hypothalamus only in strictly selected exceptional cases in highly specialized centers.

Living with cluster headaches: everyday life and self-help

• Trigger control: Strictly alcohol-free during an active phase; avoid strong smells.
• Sleep hygiene: Regular sleep-wake rhythm, if necessary avoid short naps if they trigger attacks.
• Headache diary: Document attacks, triggers, medication - helpful for adjusting therapy.
• Workplace/school: Organize certified emergency medication and, if necessary, access to oxygen.
• Stress reduction: Relaxation procedures are individual – they do not always prevent the attack, but they can reduce the stress.
• Self-help: Exchange with organizations affected by those affected can provide relief.

Course and prognosis

The process is individual. Many affected people experience recurring cluster phases over years, some turn into a chronic form, others go into longer remissions. With structured acute and prophylactic therapy, the burden of the disease can often be significantly reduced. Realistic expectation management, regular follow-up checks and early adjustments to therapy are important.

Your support in Hamburg

As a practice with a focus on conservative, functional and pain-related complaints, we advise you on diagnostics, trigger control, non-drug strategies and additional measures such as occipital nerve blocks in an individual context. If necessary, we coordinate further neurological evaluation and medication adjustment.

Address: Dorotheenstraße 48, 22301 Hamburg. You can easily arrange appointments online or by email.

When to go to the doctor – and when in an emergency?

• Extremely severe headache (“thunderclap headache”) that occurs for the first time: call 112 immediately.
• Headache with fever, stiff neck, impaired consciousness, paralysis, speech or vision problems: emergency.
• Redness/pain in the eye with loss of vision: ophthalmological emergency.
• New or changed attack patterns, lack of response to previously effective therapy: seek medical advice promptly.

ICHD‑3 criteria (simplified)

The complete assessment is carried out by a doctor; Imaging is used to rule out secondary causes of red flags.

Practical tips for the next attack

• Keep emergency medication handy (e.g. sumatriptan pen, prescribed O2 mask).
• Treat quickly when the attack begins - early use increases effectiveness.
• Find a quiet, well-ventilated place; A cold pack on the affected side can subjectively help.
• Documenting how quickly and how strongly the relief occurs - helps with adjusting therapy.