Merck Manual

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Cluster Headaches


Stephen D. Silberstein

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Reviewed/Revised Apr 2023

A cluster headache causes severe pain that is felt at the temple or around the eye on one side of the head and that lasts a relatively short time (usually 30 minutes to 1 hour). It is accompanied by nasal congestion or a runny nose and sometimes a drooping eyelid, tearing, and a flushed face. Headaches usually occur regularly during a 1- to 3-month period, followed by a headache-free period of months to years.

  • Excruciating pain occurs on one side of the head, causing the nostril and the eye on that side to water.

  • People are often restless and pace.

  • Doctors base the diagnosis on symptoms.

  • Oxygen (given by a face mask) or medications are needed to treat headaches.

  • Most people with cluster headaches need to take medications to prevent attacks from recurring.

Cluster headaches are relatively rare, affecting about 4 of 1000 people in the United States. Cluster headaches are more common among men. They typically begin between the ages of 20 and 40.

Symptoms of Cluster Headaches

A headache attack almost always starts suddenly. It may begin with nasal congestion and a watery discharge from one nostril. Excruciating pain on the same side of the head follows and spreads around the eye. The pain peaks in intensity within minutes and usually lasts 30 minutes to 1 hour but may last 15 to 180 minutes. The pain often awakens people from sleep.

After the attack, the eyelid on the same side as the headache may droop, and the pupil often constricts (called Horner syndrome Horner Syndrome Horner syndrome affects one side of the face, causing the eyelid to droop, the pupil to become small (constricted), and sweating to decrease. The cause is disruption of the nerve fibers that... read more Horner Syndrome ). The area below the eye may swell, and the eye may water. The face may be flushed. Nausea may accompany the headaches.

Headache attacks may occur several times a day, often at the same time of day or night. They usually occur regularly during a 1- to 3-month (or occasionally longer) period—called a cluster period—which is followed by a headache-free interval of several months, or even years, before attacks begin again. Alcohol may trigger headaches during a cluster period, but not during the headache-free interval. Some people do not have a headache-free interval. They have chronic cluster headaches.

Diagnosis of Cluster Headaches

  • A doctor's evaluation

  • Sometimes magnetic resonance imaging

Diagnosis of cluster headaches is based on the person’s description of the headache and the accompanying symptoms.

If the headaches have developed recently or if the pattern of symptoms has changed, magnetic resonance imaging (MRI) of the head may be done to exclude other causes.

Treatment of Cluster Headaches

  • Oxygen or a medication to stop headaches as they start

  • Medications to prevent cluster headaches over the long term

Stopping cluster headaches as soon as they start

The following may be used to stop (abort) a cluster headache as it is starting or to keep it from progressing:

Cluster headaches can also be aborted by stimulating the vagus nerve Stimulation of the vagus nerve In seizure disorders, the brain's electrical activity is periodically disturbed, resulting in some degree of temporary brain dysfunction. Many people have unusual sensations just before a seizure... read more (the 10th cranial nerve Overview of the Cranial Nerves Twelve pairs of nerves—the cranial nerves—lead directly from the brain to various parts of the head, neck, and trunk. Some of the cranial nerves are involved in the special senses (such as seeing... read more ), which carries electrical impulses between (to and from) the brain and various parts of the head, neck, and trunk. Vagus nerve stimulation can be done noninvasively (that is, without an incision in the skin or the insertion of an instrument into the body). To do so, people place a handheld device over the place on the neck where they can feel a pulse. This device sends a mild electrical current through the skin to activate the vagus nerve from outside the body. The current travels along the vagus nerve back to the brain and helps control the pain.

Preventing cluster headaches

Because cluster headaches are so severe, frequent, and incapacitating, people who have them are given medications to prevent them. These medications include

Prednisone or a nerve block may be used first because they take effect more quickly. Then one of the other drugs is used for long-term prevention.

A nerve block must be done in the doctor's office. The other treatments can be taken at home.

Drugs Mentioned In This Article

Generic Name Select Brand Names
DHE 45, Migranal, TRUDHESA
Zomig, Zomig Nasal Spray, Zomig -ZMT
7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, AsperFlex, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidocan II, DermacinRx Lidocan III, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Dologesic, Ela-Max, GEN7T, Glydo, Gold Bond, Icy Hot , LidaFlex, LidaMantle, Lido King Maximum Strength, Lidocan, LIDOCANNA, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , LidoLite, Lidomar , Lidomark, LidoPure, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, Lidtopic, Lidtopic Max, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lubricaine, Lubricaine For Her, Lydexa, MENTHO-CAINE , Moxicaine, Numbonex, Professional DNA Collection Kit, Proxivol, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Regenecare HA, Salonpas Lidocaine, Senatec, Solarcaine, SOLUPAK, SUN BURNT PLUS, Suvicort, Topicaine, Tranzarel, VacuStim Silver, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, ZiloVal, Zingo, Zionodi, ZTlido
Deltasone, Predone, RAYOS, Sterapred, Sterapred DS
EPRONTIA, Qudexy XR, Topamax, Topamax Sprinkle, Topiragen , Trokendi XR
Calan, Calan SR, Covera-HS, Isoptin, Isoptin SR, Verelan, Verelan PM
Eskalith, Eskalith CR, Lithobid
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