Cluster headaches

Cluster headaches involve frequent attacks of severe headaches, always on one side only. They mostly occur around the temples or eyes. In most cases specific migraine medication (“triptans”) or inhaling pure oxygen can alleviate the pain.

At a glance

  • Cluster headaches always occur on one side only and mostly around the temples or eyes.
  • The attacks come in phases, or “clusters”.
  • Other differences from other types of headache include concomitant symptoms such as a streaming eye, runny nose or drooping eyelid.
  • Special migraine medication or inhaling pure oxygen can ease the pain in most cases.
  • Men are affected approximately three times as often as women.

Note: The information in this article cannot and should not replace a medical consultation and must not be used for self-diagnosis or treatment.

Cluster headaches: man sitting on a park bench with his head bowed clutching his temples with both hands.

What are cluster headaches?

People who are affected by cluster headaches frequently have severe headache attacks. These always occur on one side only, mostly around the eyes or temples. Unlike other types of headache, cluster headaches have a number of typical concomitant symptoms. These include streaming eyes (often on one side only too), a runny nose or slightly drooping eyelid.  

They are called cluster headaches because the symptoms occur more frequently in phases or clusters. Most people are symptom-free between these phases. It is not known what causes cluster headaches. 

Cluster headaches are also referred to as Bing Horton syndrome. Medical practitioners classify cluster headaches as primary headaches. These also include, for example, migraine and tension headaches, which are much more common than cluster headaches but are less painful.

What are the most common types of headache?

The video below outlines the most common types of headache and how they are expressed.

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What are the symptoms of cluster headaches?

In cluster headaches piercing, stabbing or burning pain rapidly builds up around one eye. The pain is very severe and may also occur around the temples and adjoining part of the forehead. Many of those affected say that the pain feels as if a nail is being driven into their eye. 

The eye affected is often reddened and streaming. Other possible concomitant symptoms include:

  • runny or stuffy nose
  • contracted pupils
  • sweating on the forehead and cheeks
  • drooping or swollen eyelid
  • hypersensitivity to sounds or light
Indications of cluster headaches include stabbing pain around the eyes, sweating on the forehead and cheeks, a stuffy or runny nose, a drooping or swollen eyelid, hypersensitivity to sounds or light.

Many of those affected are restless or walk around during an attack as the pain eases a little when moving. An attack can last from 15 minutes up to three hours. The pain generally goes away as quickly as it came. It always affects the same side of the head in most cases.

What triggers cluster headaches?

The causes of cluster headaches are not known. Medical experts suspect, for example, that the nerve cells in the brain, which are also responsible for regulating the body’s circadian rhythms, may be hyperactive. Since cluster headaches often occur in members of the same family there may be a genetic factor at play. 

Like migraine, there are also specific triggers for attacks of cluster headache. These include, for example, various substances or situations. Many cluster headaches may be caused by drinking alcohol. Other potential triggers include:

  • periods spent at high altitudes
  • drugs containing nitroglycerin (such as vasodilatory drugs to prevent angina in people with coronary heart disease)

However, attacks are only triggered if people are already at an active phase where the cluster headaches tend to occur frequently.

Some people report that certain odors can trigger cluster headaches. Certain types of food such as certain cheeses or sausage products are often linked to the condition. However there is no proof that these types of food can trigger the attacks. 

How common are cluster headaches?

Just about one out of every 1,000 people have cluster headaches. So compared to headaches such as tension headaches or migraines, cluster headaches are very rare.

Around 0.1% of people suffer from cluster headaches.

Men are affected three times more often than women. In most cases cluster headaches appear for the first time in people aged between 20 and 40. However they may occur at any age. 

How does a cluster headache develop?

Cluster headaches normally only occur at certain phases. These phases are called clusters or episodes. They last anywhere between a few days and several weeks. Most people are symptom-free for long periods between these phases, sometimes for years. The phases and attacks often occur in spring or autumn.

During a phase of cluster headaches the attacks may occur anywhere between every other day and several times a day. They often occur repeatedly at the same time of day, particularly early in the morning or one to two hours before going to sleep. 

How can cluster headaches be prevented?

There are no known remedies to prevent someone from getting cluster headaches. However those affected can try to identify the triggers and avoid them as much as possible in order to prevent attacks. It’s a good idea for those affected to keep a diary in which they record, for example, what they had eaten or drunk or what they had been doing before an attack. 

There is medication that can help to prevent frequent attacks. The active ingredient in most of these is verapamil. However, verapamil can have adverse side effects such as cardiac arrhythmia. What’s more, this active ingredient is not an officially approved treatment for cluster headaches in Germany. Doctors can still prescribe verapamil in many cases (“off-label use”). Lithium or cortisone are also used for prevention in some cases.

How are cluster headaches diagnosed?

Doctors take a detailed medical history and conduct a physical examination to determine whether a cluster headache is indicated. This involves neurological checks such as touch perception and muscle strength. A magnetic resonance imaging (MRI) scan of the head is also usually taken to exclude other conditions as the cause of the headaches. 

How are cluster headaches treated?

Painkillers such as ibuprofen or paracetamol are not effective against acute cluster headaches. However many people find inhaling pure oxygen helpful. They use an oxygen mask connected to a special machine. It is important to ensure the correct oxygen levels are met. So the mask must cover both the mouth and nose.

Some triptan-based migraine medicines can alleviate acute cluster headaches. They are much faster acting when administered by syringe or as a nasal spray than as tablets. Hospitalization may be required at the start of the treatment.

More detailed information on cluster headaches such as what helps during an attack is available at gesundheitsinformation.de.

What is everyday life like with cluster headaches?

Cluster headaches are often described as unbearable by those who have them. During most attacks people find it impossible to concentrate on anything else, go about their everyday activities or drive. Work and family life suffer too and it is difficult to take part in leisure activities. Another stressful aspect is that the attacks frequently occur at night and can stop people from sleeping for hours at times. Many people affected by cluster headaches are unaware that they have them for a long time and are frightened that they may have a life-threatening disease. Some people even lose the will to live as a result of the cluster headaches.

A diagnosis and the knowledge that there are effective treatments for cluster headaches often brings some relief. Some changes are needed depending on the treatment. For example, people may have to learn how to live with an oxygen mask or how to inject drugs themselves.

Further information is available from gesundheitsinformation.de where people provide accounts of their own experiences of cluster headache.

In cooperation with the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen – IQWiG). As at:

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