Dr Kola Tytler MBBS CertHE MBA MSt MRCGPClinical Lead • iatroX
To differentiate cluster headaches from other primary headaches in a patient with unilateral head pain, consider the following key features:
- Location and laterality: Cluster headaches typically present with unilateral pain around or above the eye and along the side of the head/face, whereas tension-type headaches are usually bilateral and migraines can be unilateral or bilateral NICE CG150.
- Pain quality and intensity: Cluster headache pain is severe or very severe and can be sharp, boring, burning, throbbing, or tightening. Tension-type headache pain is pressing/tightening and mild to moderate, while migraine pain is pulsating and moderate to severe NICE CG150.
- Duration: Cluster headaches last 15 to 180 minutes per attack, occurring from once every other day to 8 times a day, often in bouts lasting weeks or months. Migraines last 4 to 72 hours, and tension-type headaches can last from 30 minutes to continuous NICE CG150.
- Associated autonomic symptoms: Cluster headaches are accompanied by ipsilateral autonomic symptoms such as red and/or watery eye, nasal congestion or runny nose, swollen eyelid, forehead and facial sweating, constricted pupil, and/or drooping eyelid. These are not features of migraine or tension-type headache NICE CG150.
- Effect on activities: Cluster headaches cause restlessness or agitation during attacks, whereas migraines cause avoidance of routine activities, and tension-type headaches do not aggravate daily activities NICE CG150.
- Response to treatment and referral: A first bout of cluster headache requires specialist assessment and possibly neuroimaging. Acute treatment includes oxygen and subcutaneous or nasal triptans, unlike tension-type headache or migraine NICE CKS.
Using a headache diary to record frequency, duration, severity, associated symptoms, and medication use over at least 8 weeks can aid differentiation between cluster headache and other primary headaches NICE CG150,NICE CKS.