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1 · SNAPSHOT

Cluster Headache body chart — Illustrative, not diagnostic. Canva body chart for Cluster Headache.

You will not treat this, and you may be the person who finally names it.

Illness script in one line: excruciating strictly unilateral orbital or temporal pain, 15 to 180 minutes, recurring daily in bouts lasting weeks to months, with tearing, nasal congestion and a drooping lid on the same side, and a patient who cannot sit still.

Caseload frequency: uncommon, and you will meet it. Read further: incidence and prevalence from population-based studies [1], a population-based time-trend study [2].

Why this page exists when you can't treat it

Because diagnostic delay is the norm. Read further: clinical characteristics and diagnostic delay [3], diagnostic and treatment approaches among family physicians [4]. "Misdiagnosed as migraine frequently" is the understated version of a well-documented problem.

And because two things on this page can change an outcome: spotting a secondary cause, and asking about mood.

Your three jobs: recognise it · screen it · refer it. Everything else is adjunct.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

MAIN PROBLEM

"Like a hot poker through my eye." They will use extreme language and they will be accurate. This is described as one of the most severe pains in medicine.

BODY CHART

Strictly unilateral. Orbital, supraorbital, temporal. Side-locked within a bout.
± radiation to the jaw, teeth, neck. They may have seen a dentist first.
Ipsilateral autonomic features: lacrimation, conjunctival injection, nasal congestion or rhinorrhoea, eyelid oedema, ptosis, miosis, facial sweating.

BEHAVIOUR — the clock is the diagnosis

Feature	Cluster headache
Attack duration	15 to 180 minutes untreated
Attack frequency	Every other day to eight a day
Bout pattern	Weeks to months, then remission. Often the same season each year.
Timing	Strikingly regular. Often at night, often the same hour.
Behaviour during an attack	RESTLESS. Pacing, rocking, cannot lie still.

Aggs: alcohol during a bout — and it doesn't provoke an attack outside a bout, which is diagnostically striking. Sleep, altitude, nitrates.
Eases: almost nothing they can do themselves. Cold, movement, pressure.

HISTORY

The bout pattern and the remission pattern. Episodic or chronic? Refractory chronic cluster headache has a consensus clinical definition [5].
Age and sex. More common in men, typically starting in the twenties to forties. Not a rule.
What they've been told and what they've been given. Many have been treated for migraine, sinusitis or dental pain for years.
Smoking history. Strongly associated.
Whether they have ever been to a neurologist. If the answer is no, that's your intervention.

SPECIAL / SCREENING QUESTIONS — and one of them is about mood

The full SNNOOP10 secondary headache screen.

Plus, on this page specifically: ask about mood, hopelessness and thoughts of self-harm during bouts. Cluster headache suicidality has been systematically reviewed with meta-analysis [6]. The association is established, and a student who knows it will ask.

**This is a sensitive area and it is also a clinical obligation. Ask plainly and listen. **If they have a plan or intent, or you don't think they are safe to leave: stay with them, call an ambulance (triple zero), and tell your educator now. If the answer worries you but they are not in immediate danger, get them to their GP or a mental health service the same day, with a warm handover rather than a phone number. Tell your educator.

Assessing this region? Download the Cervical Spine assessment template →

3 · HYPOTHESIS RANKING

Top three, and the one feature that separates each

Pattern	The discriminating feature
1. Cluster headache	15–180 min · up to eight a day · in bouts · ipsilateral autonomic features · RESTLESS during attacks.
2. Migraine	4–72 hours · nausea · both photophobia and phonophobia · they want to lie STILL. The behaviour during the attack is the cleanest separator.
3. Secondary trigeminal autonomic cephalalgia	A structural lesion. Systematically reviewed from published cases. Pituitary lesions are the classic. First presentation = medical referral, always.

Also on the list

Pattern	The discriminating feature
Internal carotid artery dissection	Unilateral head, face or neck pain with a partial Horner's. Reported mimicking a trigeminal autonomic cephalalgia. Escalate.
Trigeminal neuralgia	Electric-shock paroxysms of seconds, triggered by touch, chewing or cold air. Different clock entirely.
Other trigeminal autonomic cephalalgias	Paroxysmal hemicrania (shorter, more frequent) and SUNCT (seconds). The duration sorts them; a neurologist confirms.
Dental or sinus pathology	Where many of these patients spent their first two years.

4 · RED FLAGS — DON'T MISS THIS

Free forever. Safety is never behind a paywall.

The structural ones

Finding	What it means
A FIRST presentation of cluster-type headache	Medical referral, always. Read further: cluster headache due to structural lesions [7].
Visual field loss, diplopia, endocrine symptoms, galactorrhoea	Pituitary lesion. Pituitary apoplexy has presented like a trigeminal autonomic cephalalgia [8]. Urgent.
Any focal neurological deficit between attacks	Urgent. Read further: structural imaging in cluster headache [9].
Atypical duration, atypical age of onset, atypical pattern	Refer to a neurologist.
A partial Horner's — ptosis and miosis — with unilateral head, face or neck pain	INTERNAL CAROTID ARTERY DISSECTION until excluded. Reported mimicking a trigeminal autonomic cephalalgia [10]. Horner's in the cluster picture has been described [11] — which is exactly why you cannot assume it's the cluster. Do not manipulate. Escalate.

The one that's easy to forget: mood

Cluster headache suicidality has been systematically reviewed with meta-analysis [6]. The association is established. Prevalence, sickness absence and disability pension in working ages have also been examined in Neurology [12] — this is a condition that takes people out of their working lives.

What that means for you, practically:

Ask about mood and hopelessness during bouts, in plain words.
Ask about thoughts of self-harm. Asking does not plant the idea.
If they have a plan or intent, or you don't think they are safe to leave: stay with them, call an ambulance (triple zero), and tell your educator now.
If the answer worries you but there is no immediate danger: same-day GP or mental health service, don't leave them to organise it alone, and tell your educator immediately.
Undiagnosed and untreated is the worst version of this. Getting them effective medical treatment is a mental health intervention as much as a headache one.

The most valuable thing a student can do on this page is name the condition, get them to a neurologist, and ask how they're coping.

This is a sensitive topic. If you or someone you're treating is struggling, ask for help — your educator, a GP, a mental health service, or Lifeline on 13 11 14 (24 hours). In immediate danger, call triple zero (000).

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Guideline anchor

No Australian treatment guideline. NSW's emergency care protocol for headache (Agency for Clinical Innovation) covers telling cluster headache apart from more serious headache, and acute high-flow oxygen.

The treatment anchor is the American Headache Society evidence-based guidelines for the treatment of cluster headache (Robbins et al. 2016, PMID 27432623), with a clinical practice guideline for non-invasive vagus nerve stimulation (Goadsby et al. 2025, PMID 41133770) and a Bayesian network meta-analysis of episodic cluster headache treatments (Pompilio et al. 2021, PMID 33629333). The clinical anchor is a Lancet Neurology review of recent advances in diagnosing, managing and understanding cluster headache (Petersen et al. 2024, PMID 38876749). The safety anchor is a systematic review with meta-analysis of cluster headache suicidality (Van Obberghen et al. 2025, PMID 41345548).

PubMed Source

The AHS guideline is a pharmacological and interventional treatment guideline. There is no physiotherapy guideline for cluster headache, and there should not be — the physiotherapy role here is recognition, safety and adjunct management.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2008Fischera et al. (2008). The incidence and prevalence of cluster headache: a meta-analysis of population-based studies. Cephalalgia : an international journal of headache, 28(6), 614-8. https://doi.org/10.1111/j.1468-2982.2008.01592.x
2026Møen et al. (2026). The Prevalence and Incidence of Cluster Headache: A Norwegian Population-Based Time-Trend Study. Neurology, 106(11), e214862. https://doi.org/10.1212/WNL.0000000000214862
2024Nada et al. (2024). Clinical characteristics and diagnostic delay in cluster headache in Egypt. Neurological research, 46(10), 925-932. https://doi.org/10.1080/01616412.2024.2367936
2025Hasirci Bayir et al. (2025). Cluster Headache Management: Evaluating Diagnostic and Treatment Approaches Among Family and Emergency Medicine Physicians. Medicina (Kaunas, Lithuania), 61(3). https://doi.org/10.3390/medicina61030437
2014Mitsikostas et al. (2014). Refractory chronic cluster headache: a consensus statement on clinical definition from the European Headache Federation. The journal of headache and pain, 15(1), 79. https://doi.org/10.1186/1129-2377-15-79
2025Van Obberghen et al. (2025). Cluster headache suicidality: a systematic review with a meta-analysis. The journal of headache and pain, 26(1), 281. https://doi.org/10.1186/s10194-025-02140-x
2021Long et al. (2021). Cluster headache due to structural lesions: A systematic review of published cases. World journal of clinical cases, 9(14), 3294-3307. https://doi.org/10.12998/wjcc.v9.i14.3294
2026Hsu & Lee (2026). Pituitary Apoplexy with the Initial Presentations Similar to Trigeminal Autonomic Cephalalgia: A Case Report. Acta neurologica Taiwanica, 35(2), 96-98. https://doi.org/10.4103/ant.ANT-D-24-00033
2014Naegel et al. (2014). Structural imaging in cluster headache. Current pain and headache reports, 18(5), 415. https://doi.org/10.1007/s11916-014-0415-6
2026Amiraslanova et al. (2026). Raeder's paratrigeminal neuralgia secondary to internal carotid artery dissection mimicking trigeminal autonomic cephalalgia: a case report. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 47(6). https://doi.org/10.1007/s10072-026-09137-7
2019Rozen & Kline (2019). Chronic persistent Horner's syndrome in trigeminal autonomic cephalalgia subtypes and alleviation with treatment: two case reports. Journal of medical case reports, 13(1), 60. https://doi.org/10.1186/s13256-019-1986-y
2019Steinberg et al. (2019). Cluster headache: Prevalence, sickness absence, and disability pension in working ages in Sweden. Neurology, 93(4), e404-e413. https://doi.org/10.1212/WNL.0000000000007787
2016Robbins et al. (2016). Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache, 56(7), 1093-106. https://doi.org/10.1111/head.12866
2021Pompilio et al. (2021). Systematic literature review and Bayesian network meta-analysis of episodic cluster headache drugs. European review for medical and pharmacological sciences, 25(3), 1631-1640. https://doi.org/10.26355/eurrev_202102_24874
2022Akhter & Hashemi (2022). Intranasal treatment of cluster headache. Headache, 62(3), 395. https://doi.org/10.1111/head.14271
2025Goadsby et al. (2025). Non-Invasive Vagus Nerve Stimulation in Cluster Headache: A Clinical Practice Guideline. Pain practice : the official journal of World Institute of Pain, 25(8), e70084. https://doi.org/10.1111/papr.70084
2024Krymchantowski et al. (2024). Cluster headache and galcanezumab: the first real-world Brazilian study and an expert consensus on its use among other treatments. The journal of headache and pain, 25(1), 211. https://doi.org/10.1186/s10194-024-01909-w
2024Petersen et al. (2024). Recent advances in diagnosing, managing, and understanding the pathophysiology of cluster headache. The Lancet. Neurology, 23(7), 712-724. https://doi.org/10.1016/S1474-4422(24)00143-1
2019Ljubisavljevic & Zidverc Trajkovic (2019). Cluster headache: pathophysiology, diagnosis and treatment. Journal of neurology, 266(5), 1059-1066. https://doi.org/10.1007/s00415-018-9007-4
2025Lansbergen et al. (2025). 15. Cluster Headache. Pain practice : the official journal of World Institute of Pain, 25(5), e70050. https://doi.org/10.1111/papr.70050

Mapped to this pattern

HDI
Headache Disability Index
headache-related disability · 25 items · 6 min

Generic measures that also apply

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