Intended for healthcare professionals

Clinical Review

Cluster headache

BMJ 2012; 344 doi: (Published 11 April 2012) Cite this as: BMJ 2012;344:e2407
  1. Alexander D Nesbitt, research fellow12,
  2. Peter J Goadsby, professor of clinical neurology2
  1. 1Surrey Sleep Research Centre, University of Surrey, Guildford GU2 7XP, UK
  2. 2Department of Neurology, University of California, San Francisco, CA 94115, USA
  1. Correspondence to: P J Goadsby pgoadsby{at}

Summary points

  • Cluster headache is an excruciatingly painful primary headache disorder, which places an exceptional burden on those affected

  • Attacks are one sided, generally last 15 minutes to three hours, and have a characteristic set of cranial autonomic features, which are accompanied by agitation

  • Attacks occur from once every other day to eight times daily, in bouts that last several weeks, usually with complete remission between bouts

  • Treat acute attacks with high flow oxygen (12 L/min for at least 15 minutes) or parenteral triptans (or both), such as subcutaneous sumatriptan 6 mg, unless contraindicated

  • High doses of verapamil are often necessary as preventive treatment; electrocardiographic monitoring is mandatory when escalating doses

Few, if any, medical disorders are more painful than cluster headache. Previously termed migrainous neuralgia, it was last reviewed in the BMJ nearly 50 years ago.1 At that time, the authors stressed the importance of covering the topic in a general medical journal to aid recognition. Despite this remarkably prescient view, and the extreme and stereotyped nature of its presentation, cluster headache is still commonly misdiagnosed. Without a clear diagnosis, affected patients can wait many years before receiving adequate help, and they often endure unnecessary and unhelpful attempts at treatment before gaining any relief.2

Patients describe the pain of a single attack as being worse than anything else they have experienced, including childbirth. Many endure repeated attacks, lasting up to three hours, every single day. The severity of the pain has earned it the sobriquet “suicide headache,” although in our experience this is a rare occurrence in this exceptional patient group.

The management of this condition differs from that of other headache disorders. This article will review the clinical entity of cluster headache by highlighting its unique and defining characteristics as an aid to correct diagnosis, before critically appraising …

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