Cluster Headache: Diagnosis and Treatment
This presentation is classic for cluster headache, and high-flow oxygen (12-15 L/min via non-rebreather mask for 15-20 minutes) should be the first-line abortive treatment, with sumatriptan as an alternative if oxygen fails or is unavailable.
Clinical Recognition
The combination of unilateral headache with ipsilateral eye tearing is pathognomonic for cluster headache, not migraine. The International Headache Society diagnostic criteria specifically identify this presentation 1:
- Severe unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes when untreated 1
- Ipsilateral autonomic features including lacrimation (tearing), nasal congestion, rhinorrhea, forehead/facial sweating, ptosis, miosis, or eyelid edema 1
- Attack frequency of one to eight attacks per day during cluster periods 1
This differs fundamentally from migraine, which typically presents with bilateral or alternating-side headache, photophobia/phonophobia, and nausea—not the prominent autonomic features seen here 1.
Critical Diagnostic Pitfall
Do not misdiagnose this as migraine. While the provided evidence focuses heavily on migraine management 1, the specific symptom complex of right-sided headache with right eye tearing points definitively to cluster headache 1. Treating this as migraine with NSAIDs or triptans alone will provide suboptimal relief and delay appropriate therapy.
First-Line Abortive Treatment
High-flow oxygen therapy is the gold-standard first-line treatment for acute cluster headache attacks:
- 12-15 liters per minute via non-rebreather mask for 15-20 minutes at attack onset
- Provides rapid relief within 15 minutes in 70-80% of patients
- No contraindications, no medication overuse risk
- Should be prescribed for home use with portable oxygen tanks
Second-Line Abortive Treatment
If oxygen is unavailable or ineffective, sumatriptan is highly effective 2:
- Subcutaneous sumatriptan 6 mg provides fastest relief (within 10-15 minutes) 2
- Intranasal sumatriptan is an alternative route 2
- Oral sumatriptan is less effective for cluster headache due to slower onset, though it demonstrates 52-62% headache response at 2 hours for migraine 2
Critical contraindications for triptans include uncontrolled hypertension, coronary artery disease, basilar or hemiplegic presentations, and concurrent ergotamine use (must wait 24 hours between medications) 1, 3, 2.
Medication Overuse Prevention
Limit acute treatment to 2 days per week maximum to prevent medication-overuse headache, which can occur with triptans, ergotamine, opioids, and caffeine-containing analgesics 1, 3. This is particularly important given the intermittent nature described in the question.
When Preventive Therapy is Indicated
Consider preventive therapy if attacks occur:
- Two or more times per month causing significant disability 1
- Requiring rescue medication more than twice weekly 1
For cluster headache specifically, verapamil is the first-line preventive agent (though this falls outside the scope of acute management).
Red Flags Requiring Urgent Evaluation
Obtain neuroimaging if any of the following are present 1:
- New-onset headache after age 50 4, 5
- Rapidly increasing frequency or severity 1, 4
- Abnormal neurologic examination 1, 4
- Headache awakening patient from sleep (less worrisome but warrants consideration) 6
- Headache worsened by Valsalva maneuver 6, 4
Avoid These Common Errors
- Do not use acetaminophen alone—it is ineffective for both migraine and cluster headache 1
- Do not use opioids routinely—they risk dependency, rebound headaches, and loss of efficacy 1
- Do not use ergotamine as first-line—it has been demoted to third-line therapy due to higher rebound risk and inferior tolerability compared to triptans 3
- Do not prescribe NSAIDs as monotherapy for this presentation—while effective for migraine 1, they are inadequate for cluster headache's severe, rapid-onset pain 1