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Cluster Headache

Written 1st June 2020 - Last Update 20th July 2026

Cluster Headache

A trigeminal autonomic cephalalgia — see headache for the broader classification. Known as the “suicide headache” because the pain is so severe.

Presentation

  • Attacks last 15–180 minutes, frequency once every other day up to 8/day.
  • Severe, stabbing/boring, strictly unilateral in the orbital, supraorbital or temporal region.
  • Associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead/facial sweating, miosis, ptosis and/or eyelid oedema, plus restlessness/agitation.
  • Can be associated with structural lesions in/around the pituitary gland — an MRI with pituitary views is advisable.
  • Urgently refer any suspected cluster headache for expert review to confirm the diagnosis and optimise treatment; send an acute attack to the emergency department.

Management

Acute episode

  • 100% oxygen, 15 L/min via non-rebreathing mask for 15–20 minutes (monitor for oxygen toxicity).
  • Subcutaneous triptan is most effective — sumatriptan 6mg SC (risk of overdose with repeated doses).
  • Some patients respond to intranasal sumatriptan (20mg), oral rizatriptan (10mg) or zolmitriptan (2.5mg). Oral triptans are not effective as a class for cluster headache per HealthPathways.
  • Start preventive treatment once the diagnosis is made.

Long-term management

  • Verapamil — 80mg immediate-release TDS for 2 weeks, then 120mg TDS for 2 weeks, then 160mg TDS. Repeat ECG before each dose increase (exclude heart block, marked bradycardia, prolonged PR interval); do not increase the dose unless the ECG is normal.
  • Continue for ~1 week after attacks settle, then cautiously wean.
  • Consider bridging with prednisolone 50mg daily for 5 days, then reduce by 12.5mg every 3 days and stop while verapamil is introduced; or a greater occipital nerve block.
  • If no response, refer to neurology for other treatments. Galcanezumab (a CGRP monoclonal antibody) is FDA-approved for episodic cluster headache prevention but is PBS-listed in Australia only for chronic migraine, not cluster headache — off-label/specialist prescribing only.