Home / Conditions / Cluster headache
Among the most severe pain in medicine, and among the most treatable once correctly identified. Attacks come in bouts, strike one side around the eye, and often arrive at the same hour each day.
Cluster headache is severe pain on one side of the head, usually around, behind or above the eye and along the temple. People commonly describe it as drilling, boring or stabbing rather than throbbing.
The name comes from the pattern. Attacks arrive in clusters — bouts lasting weeks or months, separated by periods with no attacks at all. Within a bout, attacks often recur at the same time each day, and frequently wake people from sleep.
It is far less common than migraine, and far more often misdiagnosed as sinus trouble, dental pain or migraine — which matters, because what stops a cluster attack is not what stops a migraine.
The pain is one-sided, though some people find it swaps sides between bouts. It centres on or behind the eye and can radiate across the forehead, into the jaw, the gum line and teeth, or across the cheek. Less often it reaches the ear, neck or shoulder.
Alongside the pain, on the same side, most people have some of:
Sensitivity to light, sound or smell can occur, as in migraine. But the behaviour during an attack is different and is often the clearest clue: people with cluster headache cannot keep still. They pace, rock, or press on the eye. Lying down tends to make it worse.
The trigeminal nerve carries sensation from the face, the scalp and the structures around the eye. In cluster headache it becomes intensely activated on one side — which is why the pain sits where it does, and why it stays on that side.
That same activation sets off a reflex in the nerves controlling the eye and nose on the affected side. The tearing, the blocked or running nostril, the drooping lid and the smaller pupil are not separate problems and they are not an allergy or an infection. They are part of the attack.
It is a useful thing to know when describing the problem, because those features are precisely what distinguish cluster headache from the conditions it gets mistaken for — sinus trouble in particular.
Both are severe and one-sided, which is why they are confused. They respond to different treatment, so the distinction is worth making properly.
| Cluster headache | Migraine | |
|---|---|---|
| Onset | Sudden, peaks within minutes | Builds over hours, often with warning |
| Duration | 15 minutes to 3 hours | 4 to 72 hours |
| Character | Drilling, boring, stabbing | Throbbing, pulsing |
| During an attack | Restless, pacing; lying down worsens it | Prefers to lie still in a dark room |
| Eye and nose | Watering eye, drooping lid, blocked nostril, same side | Usually absent |
| Aura | No | Sometimes — visual disturbance beforehand |
| Pattern | Bouts of weeks or months, often at a fixed hour | Irregular, trigger-related |
Few conditions keep time like this one. Attacks frequently occur at the same hour daily, often 1–2 hours after falling asleep, and bouts can recur at the same season each year. That regularity is a diagnostic clue in itself, and it is why keeping a simple record helps more here than almost anywhere else.
Before your appointment, note down: what time attacks start, how long they last, how many a day, which side, and what the eye and nose do during one. That record is often worth more than a scan.
Diagnosis rests on the pattern and the description — the location, severity, duration, frequency and the accompanying eye and nasal symptoms. There is no blood test for it.
Assessment of sensation, reflexes and nerve function, including the nerves controlling the eye and pupil.
Not required to diagnose cluster headache, but used where the presentation is unusual or the examination raises a question, to exclude other causes of severe one-sided head pain:
Cluster headache is treated on three fronts at once: stopping the attack happening now, preventing attacks through the bout, and — where those are not enough — intervening directly on the nerves involved.
Oral painkillers are of little use here: an attack peaks faster than a tablet can work. Treatment that acts within minutes is what is needed, and options are discussed and prescribed at consultation.
Preventive medication is started at the beginning of a bout and aims to reduce how often attacks occur and how severe they are, rather than treating each one as it arrives. Which medication suits depends on your history and on what else you take.
Where medication does not control the bout, or is not tolerated, treatment can be directed at the nerves that carry the pain. Dr Tung's practice includes:
These are the options that most often distinguish specialist management from a general prescription, and they are the reason a bout that has not responded to tablets is still worth bringing in.
A sudden, severe headache unlike any you have had before — often described as the worst of your life — needs same-day assessment at an emergency department, not a clinic appointment. The same applies to a headache with fever and a stiff neck, or with new weakness, numbness, visual loss or confusion.
Cluster headache is exhausting and demoralising, particularly during a long bout. If it is affecting your mood or you are struggling to cope, say so when you call — it is a recognised part of the condition and it changes how we manage it.
No. They are separate conditions with different mechanisms and different treatment. The clearest practical differences are duration — minutes to a few hours rather than a day or more — the watering eye and blocked nostril on the same side, and restlessness instead of wanting to lie still.
Cluster headache is closely linked to the body's internal clock, which is why attacks keep to a schedule and often wake people at a consistent point in the night. It is also why bouts can recur at the same time of year.
Ordinary oral painkillers rarely help, because an attack reaches full intensity faster than a tablet is absorbed. That is not a sign that nothing works — it is a sign that the wrong kind of treatment is being used.
During a bout, alcohol commonly triggers an attack within an hour, and most people learn to avoid it until the bout ends. Between bouts it usually has no effect — a pattern that is itself characteristic.
No. You can book directly. Bring any scans and reports you already have, and your record of the attacks.
Headaches (all types) · Migraine · Silent migraine · Tension headache · Cervicogenic headache · Trigeminal neuralgia · Neuropathic pain · Neuromodulation
Bring your record of the attacks. You will leave knowing whether this is cluster headache and what can be done about the current bout.
