Cluster Headache | Diagnosis & Treatment All you need to know

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Cluster headache

Cluster Headache | Diagnosis & Treatment All you need to know

Introduction & Epidemiology

Headaches can manifest on their own but are also a very common symptom in neck pain patients as more than 60% of patients with a primary neck pain complaint report having concordant episodes of neck pain. Therefore it’s essential to find out what kind of headache the patient is suffering from.

To start off let’s differentiate between primary and secondary types of headaches. But what does this mean? Simply put, primary headaches are a “disease themselves” whereas, in secondary headaches, the headache is a symptom of another condition. So primary headaches would be migraines, tension-type headaches & cluster headaches. Secondary type headaches are headaches caused by tumors, hemorrhage, other trauma, TMJ dysfunction, substance overdose, or neck pain aka. The cervicogenic headache.

Now let’s take a closer look at cluster headaches, which are primary types of headaches.
Fischera et al. (2008) conducted a meta-analysis to assess the lifetime prevalence of cluster headache and found low numbers of 0,12% with a 1-year prevalence of 53 per 100,000 persons and the overall sex ratio was 4.3 (male to female). Cluster headache had a 1-year prevalence of 0,054%  among the working-aged population in a Swedish cohort (Manzoni et al. 2019)


The following figure shows the prevalence of headaches on different continents around the world:

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Clinical Picture & Examination

In order for a headache to qualify as a cluster headache it has to fulfill certain criteria (ICHD-III):

A. At least five attacks need to fulfill criteria B-D

B. An untreated episode lasts 15-180 minutes and shows severe or very severe unilateral orbital, supraorbital, and/or temporal pain

C. It matches either or both of the following:

  1. at least one of the following signs and symptoms, ipsilateral to the headache:
    – conjunctival injection and/or lacrimation
    – nasal congestion and/or rhinorrhoea
    – eyelid edema– forehead and facial sweating
    – miosis and/or ptosis
  2. a sense of restlessness or agitation. There are reports of patients pacing back and forth through the room, banging their heads due to the severe pain.

D. It occurs with a frequency between one every other day and 8 per day

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Treatment for cluster headache consists of medication, injections/suboccipital nerve blocks, or intracranial stimulation. We can distinguish between treatment for acute attack and preventative treatment as two facets of cluster headache management. Unfortunately, there are currently no options for physiotherapists to treat patients with cluster headaches.
Currently, only a case study has been published on the combination of endogenous neurostimulation and physiotherapy (Navarro-Fernández et al. 2019).


100% oxygen therapy is arguably the most well-known method of treating cluster headaches (Obermann et al. 2015). As compared to other types of headaches, cluster headaches are the only condition for which this strategy is a level A recommendation. A minimum of 66% of patients benefit from oxygen therapy. It takes less than ten minutes to take effect. Using oxygen has no risks or adverse effects, making it a great option for treatment. Sadly, oxygen therapy for those with cluster headaches—which can be challenging to obtain—is frequently not covered by insurance.

The only other level A-indicated therapy is triptans. Subcutaneous sumatriptan or nasal spray zolmitriptan delivery of these medications are both options (May et al. 2006). If subcutaneous injections are not tolerated, intranasal triptans might be given on the side opposite the headache. Intranasal sumatriptan (20 mg) and intranasal zolmitriptan (5 mg) are two options. As the onset period of oral medications, in whatever form, is frequently longer than the headache, they are not advised.

Alternative treatments include octreotide, ergotamine, and intranasal lidocaine (with a reported 33% response) (Matharu et al. 2004). Sadly, medication resistance develops in 10% to 20% of people with severe cluster headaches. Patients should be advised to stay away from triggers, particularly alcohol. Patients should be urged to cease smoking even though there is no evidence to suggest that doing so will reduce their likelihood of getting headaches.

Preventive Medicine

The sole tier A suboccipital blockade is advised as a method of cluster headache avoidance. Negative side effects include temporary injection site soreness and mild headaches, both of which are not significant.
The most frequently prescribed prophylactic medication is verapamil (May 2003).
For patients with persistent cluster headaches and those who have episodic cluster headaches for at least two months, it is advised as the first line of preventive treatment (Obermann et al. 2015).

For episodic and persistent cluster headaches, verapamil, which is useful as a preventive medication, is started at 240 mg once daily (Leone et al. 2000). It is advised to perform routine ECGs to check on a patient’s heart health while they are taking this medication. Verapamil has a level C recommendation, despite being widely used by healthcare professionals.

Patients with episodic cluster headaches and active cluster periods that occur infrequently and last less than two months are advised to take glucocorticoids as a preventive treatment. A study found that 70–80% of patients responded to treatment (Ekbom et al. 2002). However, they are not given for a longer period of time when alternative therapy are effective since they have severe long-term negative effects. They are especially useful when other preventive treatments take a while to start working. There is no one regimen that has been shown to be superior to the others. Oral prednisone 60 to 100 mg once daily for five days or more, with a daily dose reduction of 10 mg, is one such regimen. Combining oral and intravenous formulations is possible (Mir et al. 2003).

Lithium, valproic acid, melatonin, and intranasal capsaicin are some more pharmaceutical choices (Ekbom et al. 2002).

The effects of electrical stimulation have been extensively studied. The sphenopalatine ganglion, occipital, and vagus nerve are among the areas that are stimulated. The hypothalamus has benefited greatly from deep brain stimulation, which has been particularly effective in treating patients who are drug-resistant (Fontaine et al. 2010). A non-implanted device may offer the option of vagus nerve stimulation (Goadsby et al. 2018).

Want to learn more about headaches? Then check out our following blogs & research reviews:



Ekbom, K., & Hardebo, J. E. (2002). Cluster headache: aetiology, diagnosis and management. Drugs, 62, 61-69.

Fischera, M., Marziniak, M., Gralow, I., & Evers, S. (2008). The incidence and prevalence of cluster headache: a meta-analysis of population-based studies. Cephalalgia, 28(6), 614-618.

Fontaine, D., Lanteri-Minet, M., Ouchchane, L., Lazorthes, Y., Mertens, P., Blond, S., … & Lemaire, J. J. (2010). Anatomical location of effective deep brain stimulation electrodes in chronic cluster headache. Brain, 133(4), 1214-1223.

Goadsby, P. J., de Coo, I. F., Silver, N., Tyagi, A., Ahmed, F., Gaul, C., … & Ferrari, M. D. (2018). Non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: a randomized, double-blind, sham-controlled ACT2 study. Cephalalgia, 38(5), 959-969.

Leone, M., D’amico, D., Frediani, F., Moschiano, F., Grazzi, L., Attanasio, A., & Bussone, G. (2000). Verapamil in the prophylaxis of episodic cluster headache: a double-blind study versus placebo. Neurology, 54(6), 1382-1385.

Manzoni, G. C., Camarda, C., Genovese, A., Quintana, S., Rausa, F., Taga, A., & Torelli, P. (2019). Cluster headache in relation to different age groups. Neurological Sciences, 40, 9-13.

Matharu, M. S., Levy, M. J., Meeran, K., & Goadsby, P. J. (2004). Subcutaneous octreotide in cluster headache: Randomized placebo‐controlled double‐blind crossover study. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society, 56(4), 488-494.

May, A., Leone, M., Afra, J., Linde, M., Sándor, P. S., Evers, S., & Goadsby, P. J. (2006). EFNS guidelines on the treatment of cluster headache and other trigeminal‐autonomic cephalalgias. European Journal of Neurology, 13(10), 1066-1077.

Mir, P., Alberca, R., Navarro, A., Montes, E., Martínez, E., Franco, E., … & Lozano, P. (2003). Prophylactic treatment of episodic cluster headache with intravenous bolus of methylprednisolone. Neurological Sciences, 24, 318-321.

Navarro-Fernández, G., de-la-Puente-Ranea, L., Gandía-González, M., & Gil-Martínez, A. (2019). Endogenous neurostimulation and physiotherapy in cluster headache: a clinical case. Brain Sciences, 9(3), 60.ISO 690

Obermann, M., Holle, D., Naegel, S., Burmeister, J., & Diener, H. C. (2015). Pharmacotherapy options for cluster headache. Expert opinion on pharmacotherapy, 16(8), 1177-1184.

Olesen, J. (2018). International classification of headache disorders. The Lancet Neurology, 17(5), 396-397.

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