Neurology
Cluster Headache
군발두통
Excruciating unilateral periorbital pain with autonomic features
- How common
- 0.1% (male predominant 4:1)
- Typical age
- Men 20–40
What is it?
Posterior hypothalamic activation drives trigeminal-autonomic reflex.
Commonly affected: Unilateral orbital/temporal (V1)
How it develops
- Hypothalamic activationPosterior hypothalamus activated (circadian)
- Trigeminal activationV1 division activated
- Autonomic reflexParasympathetic → tearing/rhinorrhea; sympathetic → partial Horner
- Attack terminationSelf-terminates after 15 min – 3 hours
Symptoms
- Severe unilateral painKnown as "suicide headache"
- Cyclical attacksSame time daily, 4–12 week cluster
- Lacrimation/rhinorrheaIpsilateral autonomic features
- RestlessnessCannot lie still (unlike migraine)
- Partial HornerIpsilateral ptosis, miosis
How it is examined
- ICHD-3 criteria≥5 attacks + 1–3/day + autonomic features
- Horner examCheck for ipsilateral ptosis/miosis
- Brain MRI (once)One-time MRI to confirm primary
Imaging
Plain imaging not needed.
- Clinical diagnosis
Brain MRI to exclude secondary causes (cavernous sinus, pituitary).
- Normal
- Hypothalamic activation on fMRI
Non-surgical care
- Acute: 100% oxygen12 L/min via mask, 15 minutes
- Subcutaneous sumatriptan6 mg SC, effective in 15 min
- Prevention: verapamil240–480 mg/day (high dose)
- Short-term: steroidsPrednisolone taper
- Avoid triggersAvoid alcohol, nitroglycerine
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Refractory chronic cluster headache
Procedures that may be discussed
- Occipital nerve block
- Hypothalamic DBS
- Galcanezumab (CGRP mAb)
Outlook
Attacks self-terminate but recur; well controlled with verapamil.