Cluster Headache

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  • Typically 1-3 attacks within 24 hours, averaging 30-40 minutes each
  • Extremely intense unilateral stabbing, burning facial and eye pain with simultaneous ipsilateral autonomic symptoms (Horner syndrome, tearing, and a running nose)
  • Often occurring at night for a few hours (not in attacks)


  • Lack of sleep, alcohol, nitrates, light stimuli


  • Corneal sensitivity? (Innervation area of the ophthalmic nerve V1)
  • Rule out angle closure
  • Referral to a neurologist for further investigations and consider imaging (CT/MRI head)

Acute Therapy

  • First Choice
    • 100% oxygen 7-15L for 15-20 minutes
    • Sumatriptan (6 mg s.c.) or Zolmitriptan nasal spray (5–10 mg)
  • Second Choice
    • Sumatriptan (20mg nasal)
    • Intranasal application of Lidocaine 4–10%


  • First Choice
    • Verapamil (start at 3x 80mg per day, increase by 80mg weekly up to 480mg/day, rarely up to 960mg per day)
      • Caution: Perform an EKG due to bradycardia and AV block
    • Gradual tapering of prednisolone 100mg/day over approximately 2 weeks
  • Second Choice
    • Lithium (plasma level: 0.6-1.2 mmol/l)
    • Topiramate (start with 50mg/day, increase by 50mg weekly up to 100-200 mg/day)
  • Others: Topical application of 0.5% Capsaicin ointment in the ipsilateral nostril