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Headaches: Cluster


An in-depth report on the causes, diagnosis, treatment, and prevention of cluster headaches.

Cluster Headaches

Cluster headaches are among the most painful of all headaches. The signature is a pattern of periodic cycles of headache attacks, which may be one of the following:

  • Episodic (occurring regularly for weeks to months, followed by long pain-free periods), or
  • Chronic (occurring without sustained breaks).

It should be noted that a significant percentage of people who experience a first cluster attack do not have another one.

Episodic Cluster Headaches. Between 80% and 90% of cluster headache patients have episodic cluster headache cycles.

Chronic Cluster Headaches. About 10% to 20% of cluster headache patients have a chronic form that lasts more than a year, with remissions lasting less than 14 days. Two chronic subtypes have been defined:

  • Chronic cluster headache that is unremitting from the onset. This type may be more commonly associated with heavy alcohol use.
  • Chronic cluster headache that has evolved from episodic cluster. One study found a higher risk for this form in patients who developed cluster headaches in their thirties or older and who had more frequent attacks and shorter remissions than average. Another study suggested that this condition occurs more often in heavy smokers, although the link is uncertain.

Symptoms of Cluster Headaches

Cluster symptoms tend to occur during spring, autumn or both and they most often occur at night. The course of symptoms varies and may include the following:

Prodromal Symptoms. Over half of cluster headache patients experience warning symptoms, long before an attack. They are called prodromal, or premonitory, symptoms. Such symptoms occur from one day to up to two months before an actual cluster headache attack. (On average, they develop about week before an attack.) They include the following:

  • Strange tingling sensations around the eye, nose, or neck (occurs in about third of patient who have prodromal symptoms).
  • Nasal congestion or runny nose, excessive tearing (in about two thirds of patients).
  • Feeling restless or depressed (about two thirds of patients).
  • Other premonitory symptoms reported include fatigue, neck ache, stiffness, odd sensations in the limbs, or an extreme sensitivity in the area where the headache will develop.

Symptoms Signaling the Onset of an Attack. Over three-quarters of patients report tingling sensations and irritability minutes to hours preceding an attack. A minority of patients experience migraine-like auras (which are odd sensory experiences, such as seeing shimmering light or blind spots).

Symptoms of a Cluster Headache Attack. When the actual attack occurs, symptoms typically escalate rapidly (within about 15 minutes) to intense levels. People often awaken with them a few hours after they go to bed.

The pain usually develops as follows:

  • The pain is typically described as severe, stabbing or boring.
  • It is virtually always on one side, although it may occur on the opposite side in other attacks or even within the same attack. In most cases the pain is centered behind one eye or near the temple.
Pain of cluster headache
The symptoms of a cluster headache include stabbing severe pain behind or above one eye or in the temple. Tearing of the eye, congestion in the associated nostril, and pupil changes and eyelid drooping may also occur.
  • The pain often radiates to other parts of the head, such as the forehead, cheek, jaw, or upper or lower teeth. Less commonly it radiates to the ear, nose, neck, or shoulder. (This occurs more often in chronic cluster headache sufferers than those with the episodic form.)
  • Pain does not worsen with movement (as it often does with migraine headaches).

Other symptoms include the following:

  • Excessive tearing, a drooping eyelid, and one stuffy or runny nostril. All of these symptoms appear on the same side as the pain.
  • Feelings of intense restlessness and agitation. People in the throes of a cluster headache may pace the floor or may even bang their heads against the wall in an attempt to cope with the pain. These are common events and help differentiate a cluster from a migraine attack (in which people have a tendency to sleep).
  • Facial sweating.
  • Nausea. (According to one study this occurs in about half of people.)
  • Intolerance to light (in one eye), sounds, or smells can occur.
  • Migraine-like auras marked by visual, motor, or speech disturbances. Such events occur in between 6% and 14% patients and may be associated with a personal or family history of migraine headaches.
  • Rarely, partial and temporary paralysis.

Typical Cluster Cycles

Timing of an Attack: Headache attacks tend to occur with great regularity at the same time of day. About 75% occur between 9 at night and 10 in the morning. Peaks have also been reported between 1 PM and 3 PM.

Duration of an Attack. A single cluster attack is usually brief but extremely painful, lasting about one to three hours. (In one study the average attack lasted 72 minutes.)

Number of Attacks per Day During the Cycle: During an active cycle, sufferers can experience these attacks as infrequently as one every other day to several attacks a day.

Duration of a Cycle: Cycles of such daily or near daily attacks typically occur over the course of a week to a year--most often in spring and autumn. Usually a patient has one or two cycles per year that each last one to three months. (In one study of cluster headache suffers, most individuals experienced one cycle a year that lasted on average about eight and half weeks.)

Headache-Free Remissions Between Cycles: Such cycles are followed by headache-free periods lasting at least fourteen days, and often for many months. Sustained remissions may last as long as 20 years.


Migraine Headache: General Description of Its Course

Migraine is now recognized as a chronic illness, not simply as a headache. They are often classified by whether auras accompany them or not:

  • Common migraines are without auras. About 75% of migraines are the common type.
  • Classic migraines are those with auras.

A person may experience one or the other at different times. In general, there are four symptom phases to a migraine (although they may not all occur in every patient): the prodrome, auras, the attack, and the postdrome phase.

Prodrome. The prodrome phase is a group of vague symptoms that may precede a migraine attack by several hours, or even a day or two. Such prodrome symptoms can include the following:

  • Sensitivity to light or sound.
  • Changes in appetite.
  • Fatigue and yawning.
  • Malaise.
  • Mood changes.
  • Food cravings.

Auras. Auras are sensory disturbances that occur before the migraine attack in between 20% and 25% of patients. Visually, auras are referred to as being positive or negative:

  • Positive auras include bright or shimmering light or shapes at the edge of their field of vision called scintillating scotoma. They can enlarge and fill the line of vision. Other positive aura experiences are zigzag lines or stars.
  • Negative auras are dark holes, blind spots, or tunnel vision (inability to see to the side).

Patients may have mixed positive and negative auras. This is a visual experience that is sometimes described as a fortress with sharp angles around a dark center.

Other neurologic symptoms may occur at the same time as the aura, although they are less common. They include the following:

  • Speech disturbances.
  • Tingling, numbness, or weakness in an arm or leg.
  • Perceptual disturbances such as space or size distortions.
  • Confusion.

Migraine Attack. If untreated, attacks usually last from four to 72 hours. A typical migraine attack produces the following symptoms:

  • Throbbing pain on one side of the head. The word migraine, in fact, is derived from the Greek word hemikrania, meaning half of the head because the pain of migraine often occurs on one side. Pain also sometimes spreads to affect the entire head.
  • Pain worsened by physical activity.
  • Nausea, sometimes with vomiting.
  • Visual symptoms.
  • Facial tingling or numbness.
  • Extreme sensitivity to light and noise.
  • Looking pale and feeling cold.
  • Less common symptoms include tearing and redness in one eye, swelling of the eyelid, and nasal congestion, including runny nose. (Such symptoms are more common in certain other headaches, notably cluster headaches. In one study, however, they occurred in over 40% of migraine sufferers.)

Postdrome. After a migraine attack, there is usually a postdrome phase, in which patients may feel exhausted and mentally foggy for a while.

Tension-Type Headache

Tension-type headaches, also called muscle contraction headaches or simply tension headaches, are the most common of all headaches. Tension-type headaches can last minutes to days and may have the following characteristics:

  • The pain is commonly described as a tight feeling, as if the head were in a vise. It usually occurs on both sides of the head and is often experienced in the forehead, in the back of the head and neck, or in both regions. Soreness in the shoulders or neck is common.
  • Depression, anxiety, and sleeping problems may accompany persistent headaches.

Sufferers of tension-type headaches may also have migraine-like symptoms, including being sensitive to light or noise (but not both). Some patients also may suffer from visual disturbances. (Such symptoms in tension headaches, however, tend to be less severe than in migraine. Tension headaches also do not cause nausea or limit activities to the degree that migraines do.) [For more information, seeWell-Connected Report #11, TensionHeadache.]

Other Primary Headaches

Chronic Paroxysmal Hemicrania. Chronic paroxysmal hemicrania is a close relative of cluster headache and very similar. It causes multiple, short, and severe daily headaches with similar symptoms. Unlike cluster headaches, the attacks are shorter (one to two minutes) and more frequent (occurring an average of 15 times a day). This headache is even rarer than cluster headache, tends to occur in women, and always responds to treatment with indomethacin.

Hemicrania Continua. Hemicrania continua occurs mostly in women. The patient generally experiences continuous low-level headache always on one side of the face. Periodic attacks can last days to weeks, which can be mild to severe, and may resemble migraines. (About 10% of patients experience remissions.) The headaches can usually be treated successfully with indomethacin, which helps differentiate if from other headaches, notably migraines.

SUNCT Syndrome. A disorder called SUNCT syndrome (which stands for Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing) causes stabbing or burning eye pain that may resemble cluster headaches, but attacks are very brief (lasting about a minute) and may occur more than 100 times per day. Red and watery eyes, sweating forehead, and congestion are typical. This rare headache is more common in men and does not respond to other headache treatments.


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