Examqo › Examqo library › Neurology › Headache and facial pain · IMLE
Cluster headache and trigeminal autonomic cephalalgias
Cluster headache is a severe one-sided pain around the eye, short and accompanied by tearing and a runny nose on the same side, arriving in attacks at fixed hours — and acute treatment is 100 percent oxygen or injected sumatriptan.
Why it matters in the exam
Questions describe a man woken at night by terrible pain behind the eye, pacing the room restlessly, with a watering red eye and a runny nostril on the same side, for a few weeks every year. They test the difference from migraine (in migraine patients lie still in the dark), the acute treatment, prevention with verapamil and ECG monitoring, and the related headaches: paroxysmal hemicrania with an absolute response to indomethacin, and SUNCT with attacks lasting seconds. A common distractor is an oral triptan, which acts too slowly.
Key points
- Cluster headache: one-sided around the eye, 15 to 180 minutes, with autonomic symptoms and restlessness.
- Acute treatment: 100 percent oxygen by mask or sumatriptan 6 mg subcutaneously.
- Prevention with verapamil and ECG monitoring, with a steroid bridge.
- Paroxysmal hemicrania and hemicrania continua respond absolutely to indomethacin.
- SUNCT: attacks of seconds, lamotrigine and MRI.
Summary table
| Type | Attack duration and frequency | Key treatment |
|---|---|---|
| Cluster headache | 15 to 180 minutes, up to 8 a day, in bouts of weeks to months, mostly in men | Acute: 100 percent oxygen 12 to 15 litres per minute by mask for 15 minutes, or sumatriptan 6 mg subcutaneously; prevention: verapamil |
| Paroxysmal hemicrania | 2 to 30 minutes, more than 5 a day, more common in women | Absolute response to indomethacin, which is part of the diagnosis |
| Hemicrania continua | Continuous one-sided pain with exacerbations and autonomic symptoms | Absolute response to indomethacin |
| SUNCT and SUNA | 1 to 600 seconds, dozens of attacks a day | Lamotrigine; MRI to exclude a lesion |
| Prevention and work-up | Verapamil needs an ECG before each dose increase; steroids or an occipital nerve block as a bridge; lithium as an alternative | MRI of the brain and pituitary region in any atypical presentation |
A free exam question
בן 30 עם כאב ראש חזק לאחר הרמת משקל כבד בחדר כושר, עבר CT מוח ודיקור מותני שהיו תקינים. בעברו 20 אירועים דומים שכולם התרחשו בהרמת משקל כבד בחדר כושר. דימום לאחרונה מהקיבה מונע שימוש ב NSAIDS . איזה טיפול נוסף יכול להוריד את כמות התקפי כאב ראש? (the question as examined, in Hebrew)
- א. Triptans
- ב. Propranolol
- ג. Topiramate
- ד. Verapamil
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Neurology, Medical licensing exam (IMLE), Internal medicine, Family medicine, Emergency medicine.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- International Classification of Headache Disorders, 3rd edition (ICHD-3), 2018 — Trigeminal autonomic cephalalgias
- EFNS Guidelines on the Treatment of Cluster Headache and Other Trigeminal-Autonomic Cephalalgias, 2006 — Acute and preventive treatment
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.