History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include family history, male sex, head injury, heavy smoking, and heavy drinking.

repeated attacks of unilateral pain

Rapid onset of unilateral pain in the orbital, peri-orbital, and/or temporal region. The frequency of attacks is from 1 every other day to a maximum of 8 per day.[2] Higher numbers of attacks should raise suspicion of paroxysmal hemicrania.

short duration

Pain peaks within minutes and lasts for approximately 15 to 180 minutes before rapidly subsiding.[2]

excruciating pain

Pain is excruciating. It is described as the worst pain ever experienced, with women comparing it to childbirth. Often the pain is described as boring, sharp, piercing, burning, or pulsating. Several patients will complain of a constant pressing or burning background pain or 'shadows' between acute attacks. Suicidal thoughts are common (reported in 55% to 64% of patients) as a result of the pain.[1][26]

lacrimation, rhinorrhoea, and partial Horner syndrome

International Headache Society criteria require at least one autonomic feature for diagnosis, although autonomic features are absent in 3% of patients.[2] Lacrimation is the most frequent symptom, followed by conjunctival injection, nasal congestion, rhinorrhoea, and partial Horner syndrome (ptosis and miosis). 

agitation and restlessness

Most patients are agitated and restless. They might pace, rock back and forth, vocalise, or bang their head against the wall.[1]

Risk factors

strong

male sex

The reported male:female ratio is approximately 2.5:1.[1][5]

family history

Twin and family studies show a 14-fold increase in risk in first-degree relatives of patients with cluster headache and a twofold increase in second-degree relatives.[1][5][12] However, in most cases there is no family history of cluster headache.

head injury

A high proportion of patients have a history of head trauma with concussion, but causative links are not established.[8][9]​​[17]​​

cigarette smoking

There is an association between cluster headache and heavy tobacco smoking, but smoking cessation does not reduce the frequency of cluster headache attacks.[1][8][9] However, smoking does increase the risk of coronary artery disease, which can influence treatment. Tobacco exposure in the form of second-hand smoke may also affect the clinical presentation.[18]

heavy drinking

There is an association between heavy alcohol consumption and cluster headache, and alcohol is often an immediate trigger for an attack during a cluster period.[8][9]

Use of this content is subject to our disclaimer