CBL: Cluster Headache

Learning Objectives

• Recognize cluster headache as severe, peri-orbital pain with ipsilateral autonomic features.
• Identify high-flow oxygen as an effective acute therapy.
• Describe preventive therapy, especially verapamil.

Vignette

BA is a 38-year-old man with two weeks of recurrent sharp right peri-orbital pain lasting up to a couple of hours, then resolving. Attacks recur during the workday; codeine and ibuprofen were ineffective. No nausea, vomiting, or visual change. During attacks he notes right eye redness and tearing and a slight droop of the eyelid. He worries about missing work in a mechanical parts assembly plant.

PMH: Left knee surgery after sports injury; no regular meds; no known drug allergies. SH: Smokes 1 ppd, drinks 1–2 beers/day. FH: Premature coronary disease and alcoholism. ROS: Negative for fever, jaw claudication, joint pain, dysphagia/odynophagia.

Examination

Moderate distress, downcast posture. Right conjunctiva injected and tearing; mild right ptosis. Pupils equal and reactive. Fundi normal; no photophobia. Cardiovascular exam and carotids normal. EOMI; facial expression and sensation intact; no temporalis tenderness; hearing normal. CN XI, palate, and tongue normal. Strength and tone normal without tremor; DTRs symmetric; sensation intact; coordination and gait normal.

Localization & Neuroanatomy

Symptoms localize to the ophthalmic/maxillary branches of the trigeminal distribution (V1 & V2) with prominent cranial autonomic activation (tearing, conjunctival injection, ptosis).

Diagnosis & Differential

Recurrent unilateral peri-orbital pain lasting 20–180 minutes with ipsilateral autonomic features strongly supports cluster headache. Differentiate from closed-angle glaucoma, temporal arteritis (check ESR/CRP if suspected), migraine (often longer with photophobia/nausea), trigeminal neuralgia (seconds-long, lancinating; no autonomic signs), and SUNCT (very brief, frequent attacks with conjunctival injection and tearing). Rare mimics include Tolosa–Hunt, intracranial aneurysm, and cavernous sinus thrombosis.

Treatment

Acute: High-flow oxygen (e.g., ~15 L/min via nonrebreather for 10–20 min) and subcutaneous or intranasal triptans are effective. Opioids are generally ineffective and not recommended.

Preventive: Verapamil is first-line. Alternatives for refractory cases include lithium, topiramate, and magnesium; short corticosteroid tapers can be used as a bridge. Counsel on smoking cessation, which is associated with cluster headache and benefits overall vascular risk.

Teaching Points

• Attacks last 20–180 minutes, often at the same time daily in clusters.
• Cranial autonomic features (tearing, conjunctival injection, ptosis) are key.
• Oxygen is a highly effective, non-sedating acute therapy.
• Verapamil is the cornerstone of prevention; consider ECG monitoring at higher doses.

References

1. Module adapted from provided teaching text on cluster headache, emphasizing autonomic features, oxygen responsiveness, and verapamil prophylaxis.