What cluster headache is
Cluster headache is a primary headache disorder, not a severe migraine. Attacks are strictly one-sided, usually around or behind one eye, with autonomic features on the same side (watering eye, drooping eyelid, blocked or runny nostril, sweating). They last 15 to 180 minutes, often happen at the same time each day, and come in bouts ("clusters") lasting weeks to months separated by remission. Severity is exceptional — it is consistently rated one of the most painful conditions known.
NICE CG150 in plain English
NICE CG150 (Headaches in over 12s) covers cluster headache alongside migraine, tension-type and medication overuse headache. For cluster, the key recommendations are:
- Diagnose clinically using the pattern above. Imaging (MRI) is recommended at first presentation to rule out secondary causes.
- Refer everyone with suspected cluster headache to a specialist (neurology).
- Offer 100% oxygen and/or subcutaneous sumatriptan for acute attacks.
- Offer verapamil for prophylaxis (with ECG monitoring), with specialist input on dosing.
Acute attack treatment
- 100% oxygen, 12 to 15 L/min via a non-rebreather mask, used at the onset of an attack for 15 to 20 minutes. Funded on the NHS via a Home Oxygen Order Form (HOOF) — usually prescribed after neurology assessment, sometimes by GPs working with a neurology letter.
- Subcutaneous sumatriptan 6mg by auto-injector. Works within minutes. Up to two doses in 24 hours.
- Nasal sumatriptan or zolmitriptan as alternatives if subcut isn't tolerated.
- Oral triptans, paracetamol, ibuprofen and codeine are not effective fast enough for cluster attacks and should not be the only treatment offered.
Prevention
- Verapamil is the first-line preventive. Started low (e.g. 80mg three times daily) and titrated up under specialist guidance. ECG monitoring is required before starting and at dose increases because verapamil can prolong the PR interval.
- Short tapering course of oral corticosteroids (e.g. prednisolone) can be used as a bridge while verapamil takes effect, on specialist advice.
- Other preventives for chronic cluster (lithium, topiramate, greater occipital nerve block, and galcanezumab in some specialist settings) are managed by neurology, not primary care.
Neurology referral
CG150 recommends specialist referral for everyone with cluster headache. Neurology does three things primary care can't easily do: confirms the diagnosis (and arranges MRI if not already done), arranges home oxygen via the HOOF form, and manages verapamil titration with ECG.
If your GP is hesitant, ask for the referral in writing and ask for it to be coded as suspected cluster headache, NICE CG150. Many areas have a headache clinic within neurology with shorter waits than general neurology.
What to ask your GP
- Referral to neurology (or a headache clinic) under NICE CG150.
- Subcutaneous sumatriptan 6mg auto-injector for acute attacks, now, rather than waiting for the neurology appointment.
- A plan for home oxygen via a HOOF form once neurology confirms.
- If verapamil is started, the required ECG monitoring.
- An MRI brain to rule out secondary causes if not already done.
If your GP won't engage or offers only oral painkillers, a formal letter naming CG150 and the two NICE-recommended acute treatments is usually what unlocks the conversation. Finally Seen writes that for £49.
Frequently asked questions
›Is cluster headache the same as migraine?
No. Cluster headache is a distinct trigeminal autonomic cephalalgia. Attacks are typically strictly one-sided around the eye or temple, last 15 to 180 minutes, and come in clusters of weeks or months. It is sometimes called 'suicide headache' because of how severe attacks are. Migraine treatments often don't work for it.
›Why is high-flow oxygen important?
NICE CG150 recommends 100% oxygen at 12 to 15 litres per minute via a non-rebreather mask for acute cluster attacks. It works for most people within 15 to 20 minutes. It's funded on the NHS via a Home Oxygen Order Form (HOOF) prescribed by a clinician, usually after neurology assessment.
›What about sumatriptan injections?
Subcutaneous sumatriptan (6mg auto-injector) is the other NICE-recommended acute treatment. Oral triptans are too slow for cluster headache. Nasal sumatriptan or zolmitriptan are alternatives. Tablets you swallow are not effective fast enough.
›What's used to prevent cluster headache?
Verapamil is the first-line preventive in CG150, started at a low dose and titrated up with ECG monitoring. A short tapering course of oral corticosteroids is sometimes used as a bridge while verapamil takes effect. Lithium and other options exist for chronic cluster.
›Do I need to see a neurologist?
Yes. NICE CG150 recommends specialist (neurology) referral for everyone with cluster headache, especially to confirm diagnosis, arrange home oxygen, and manage preventives. A GP can start verapamil and refer in parallel.