Cluster Headache
NICE Clinical guideline [CG150] Headaches in over 12s: diagnosis and management. Last updated Dec 2021.
NICE CKS Headache – cluster. Last revised Apr 2022.
Guidelines
Headache Red Flags
If headache and ANY of the following, consider the need for further investigations and/or referral:
-
worsening headache with fever
-
sudden‑onset headache reaching maximum intensity within 5 minutes
-
new‑onset neurological deficit
-
new‑onset cognitive dysfunction
-
change in personality
-
impaired level of consciousness
-
recent (typically within the past 3 months) head trauma
-
headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
-
headache triggered by exercise
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orthostatic headache (headache that changes with posture)
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symptoms suggestive of giant cell arteritis
-
symptoms and signs of acute narrow angle glaucoma
- a substantial change in the characteristics of their headache
If new-onset headache and ANY of the following, consider the need for further investigations and/or referral:
- Immunocompromised (e.g. HIV, use of immunosuppressive drugs)
- <20 y/o + history of malignancy
- History of malignancy known to metastasise to the brain
- Vomiting without other obvious causes
Investigation and Diagnosis
NICE recommends considering the use of a headache diary for at least 8 weeks to aid the diagnosis of primary headaches. The person should record the following:
- Frequency, duration and severity of headaches
- Any associated symptoms
- Possible precipitants
- Relationship of headaches to menstruation
- All medications taken to relieve headaches
Do not refer people diagnosed with tension‑type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.
NICE recommends clinical diagnosis, according to the following headache features:
| Headache feature | Seen in cluster headache |
|---|---|
| Pain location | Unilateral (around the eye, above the eye and along the side of the head / face) |
| Pain quality | Variable (sharp / boring / burning / throbbing / tightening) |
| Pain intensity | Severe or very severe |
| Duration | 15-180 minutes |
| Effect on activities | Restlessness or agitation |
| Other symptoms | Ipsilateral autonomic features:
|
Management
Acute Management
Offer:
- Short-burst oxygen therapy (100% oxygen at >12 L/min with a non-rebreathing mask and reservoir bag), AND/OR
- Subcutaneous or nasal triptan (subcutaneous sumatriptan injection or zolmitriptan intranasal spray)
- For adutls >18 y/o
- Triptan is contraindicated in the presence of cardiovascular disorders, previous TIA / CVA, and severe hepatic impairment
Discuss the need for neuroimaging for first bout of cluster headache with a specialist.
Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache.
Prophylactic Management
Consider verapamil
References
Original Guideline