Cluster headache
This is one of the most severe pains medicine knows and, at the same time, one of the most recognisable: always on one side, always around or behind the eye…
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Medicines commonly prescribed for Cluster headache
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: MODIFIED-RELEASE TABLET, 87 mg valproic acid, 200 mg sodium valproateActive substance: valproic acidManufacturer: Sanofi Aventis S.A.Prescription requiredDosage form: INJECTABLE, 400 mgActive substance: valproic acidManufacturer: Altan Pharmaceuticals SaPrescription requiredDosage form: TABLET, 50 mg of sumatriptan (as sumatriptan succinate)Active substance: sumatriptanManufacturer: Teva Pharma S.L.U.Prescription required
This is one of the most severe pains medicine knows and, at the same time, one of the most recognisable: always on one side, always around or behind the eye, arriving without warning and, an hour or two later, leaving just as abruptly. Between attacks the person is perfectly well. It is uncommon — roughly one person in a thousand — and that is exactly why years often pass between the first attack and the right diagnosis, years in which healthy teeth get pulled and sinus infections that were never there get treated. The good news is that once it is named correctly, an attack can be stopped in minutes and a whole bout can be broken.
What an attack is like
The pain climbs fast: five to ten minutes from the first hint to the peak. It burns, bores or stabs, sits around the eye socket and can spread to the temple, the upper jaw and the teeth. In any one person the side is almost always the same. An attack lasts from a quarter of an hour to three hours and then stops of its own accord.
Signs appear on that side that you do not get with other headaches:
- the eye reddens and waters;
- the eyelid droops and swells, and the pupil is smaller than on the other side;
- one nostril runs or, conversely, blocks completely;
- the face and forehead sweat, and the ear on that side may feel hot.
One detail is very telling: behaviour. With migraine a person lies down and keeps still in the dark, because movement makes it worse. With cluster headache sitting still is impossible — people pace the room, rock, press their head against the wall, step out into the cold. That restlessness is so characteristic that doctors use it as a diagnostic clue.
An attack often wakes people an hour or so after falling asleep and returns day after day at the same time, as though the body had set an alarm.
Why "cluster"
The name describes the rhythm. Attacks come in bouts: for weeks or months the pain arrives one to eight times a day, then vanishes entirely for months or years. In many people the bouts are tied to the season and begin in roughly the same weeks each time, most often around the turn of autumn and spring.
In about one person in ten there are no clear spells at all, or they last under a month; that form is called chronic. It is harder going and needs more persistence in finding the right treatment, but it responds too.
Cluster headache usually starts between twenty and forty, more often in men and considerably more often in smokers. The origin lies not in the blood vessels or the sinuses but in the region of the hypothalamus, the part of the brain that runs the daily clock. That is where both the seasonality and the punctuality at night come from.
What it gets mistaken for
Pain in the upper jaw and behind the eye is what misleads most. People are treated for sinusitis for years — the nose really is blocked — and have upper teeth taken out because those teeth really do hurt. The distinction is simple: in a cluster attack the pain arrives and leaves within minutes rather than dragging on for days, and nothing at all is left between attacks.
Migraine is confused with it less often: there the pain throbs, lasts from a few hours to three days, comes with nausea and an intolerance of light and sound, and the person wants darkness and stillness rather than movement. Another neighbour is trigeminal neuralgia: a pain like an electric shock, lasting seconds, set off by a touch, by shaving or by chewing.
It is worth knowing what is not on the list either: ordinary painkillers do not work in cluster headache. A tablet cannot take effect before the attack ends by itself, and taking them often adds a second problem on top of the first — medication overuse headache.
When this is not an appointment but an emergency
Cluster headache itself is not life-threatening, but its appearance can mask conditions where hours count. Call emergency services or go to an emergency department if:
- the headache came on instantly and hit its peak within seconds, like a blow — that is how bleeding under the membranes of the brain starts;
- the eye is red and hard, vision is blurred, there are coloured halos around lights, and there is nausea and vomiting — this may be an acute attack of glaucoma;
- a drooping eyelid and a small pupil have appeared for the first time, especially alongside neck pain and a recent sharp movement of the head — that is how a carotid artery dissection shows itself;
- the pain comes with weakness or numbness in an arm or a leg, trouble speaking, double vision or a seizure;
- there is a high fever, a dislike of light, a stiff neck, or a rash that does not fade when pressed;
- you are over fifty and your temple hurts, your scalp is sore to touch or to comb, your jaw aches and tires while chewing, and vision is clouding — those are the signs of temporal arteritis, where delay costs eyesight.
Separately and plainly: during an attack the pain can be strong enough to bring on thoughts of ending it at any cost. That has to be said to a doctor out loud rather than borne in silence, and if such thoughts come, help should be sought immediately. It is neither weakness nor exaggeration — it is a known feature of the illness, and it is treated along with it.
How to stop an attack
Only things that act within minutes are of any use, and there are two of them.
Oxygen. Breathing pure oxygen through a tight-fitting non-rebreather mask ends the attack in most people within fifteen to twenty minutes. This is not a home improvisation: the equipment and the regimen are set by a doctor, and at home a concentrator or a cylinder is needed. Nobody may smoke or light a flame near oxygen.
Triptans. Only the fast forms help — a subcutaneous injection or a nasal spray; tablets are far too slow for this pain. These medicines interact with certain drugs and are unsuitable in a number of heart and vascular conditions, so they are prescribed by a doctor rather than picked off a shelf.
There are also devices that stimulate the vagus nerve through the skin of the neck; they are used as an addition when the first two options do not fit.
How to break the bout
While a bout is running, the aim is not only to put out individual attacks but to end the series. The mainstay remains verapamil, a calcium channel blocker; the dose is built up gradually and always monitored with an ECG, because the drug affects conduction in the heart. To buy time while verapamil comes up to strength, a short course of corticosteroids or a greater occipital nerve block on the affected side is used. In the chronic form other medicines come into play and, in rare stubborn cases, implanted neurostimulators. All of this is chosen by a neurologist — experimenting alone here is useless and not without risk.
Some of it depends on you alone. Inside a bout, alcohol sets off an attack almost without fail, usually within the hour, so for those weeks it is dropped entirely. Nitrates, the sharp smell of solvents and varnishes, overheating, altitude and flights, daytime naps and a broken sleep schedule all do the same. Outside a bout those same triggers usually do nothing at all. And separately there is smoking: quitting will not cut a bout short on the spot, but in those who stop, attacks grow less frequent and milder over time.
What to write down and what to bring to the doctor
No test and no scan confirms cluster headache — the diagnosis is made from the account, which makes a diary worth more than any investigation. Note the date, the exact time the attack started and finished, the side, how bad it was, what happened to the eye and the nose, what you took and how long it took to work, and what came beforehand.
It is worth seeing a doctor as soon as the attacks begin to repeat, and not putting it off if the pain gets longer, changes sides, stops fitting the familiar pattern, or the usual treatment stops working. Some people are referred to a neurologist and sent for a scan — not because it will show cluster headache, but to rule out other causes that look similar.
Online consultation
Conversation is the main instrument in this diagnosis, so a remote appointment works here at almost full strength. Online it is easy to go through the diary and work out whether this looks like cluster headache, migraine or neuralgia; to discuss why painkillers are not helping and what to ask for instead; and to prepare for the neurology appointment knowing what to raise. For those already on treatment, a doctor can track how it is being tolerated, remind you about ECG monitoring on verapamil, and go through what to do when a bout returns. The signs on the emergency list cannot be judged through a screen — with those, seek urgent care straight away.
This material is for information only and does not replace medical advice.
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