Cluster headaches are known to be one of the most painful conditions that patients can have the misfortune to suffer. The name relates to the pattern of the headaches - they typically occur in clusters lasting several weeks, with the clusters themselves typically once a year.

Cluster headaches are more common in men (3:1) and smokers. Alcohol may trigger an attack and there also appears to be a relation to nocturnal sleep.

PC

• pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
• clusters typically last 4-12 weeks
• intense sharp, stabbing pain around one eye (recurrent attacks 'always' affect same side)
• patient is restless and agitated during an attack
• accompanied by redness, lacrimation, lid swelling
• nasal stuffiness
• miosis and ptosis in a minority

Management

• acute: 100% oxygen (80% response rate within 15 minutes), subcutaneous triptan (75% response rate within 15 minutes)
• prophylaxis: verapamil is the drug of choice. There is also some evidence to support a tapering dose of prednisolone
• NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging