Cluster Headaches

Medically Reviewed by Zilpah Sheikh, MD on July 21, 2024
Written by Robert Beck
10 min read

Cluster headaches are a series of relatively short but very painful headaches that happen every day for weeks or months at a time. You tend to get them at the same time each year, such as in the spring or fall. Because of this, people often mistake cluster headaches for symptoms of allergies or work stress.

Experts don't know what causes them, but a nerve in your face is involved, creating intense pain around one of your eyes. It's so bad that most people can't sit still and will often pace during an attack. Cluster headaches can be more severe than migraine s, but they usually don't last as long.

These are the least common type of headaches, affecting fewer than 1 in 1,000 people. Men get them more than women do. You usually start getting them before age 30. Cluster headaches may go away completely (this is called going into remission) for months or years, but they can come back without any warning.

There are two types of cluster headaches. They differ based on how long the periods of your attacks last.

Episodic cluster headaches. These attacks happen over a period of weeks to months, separated by remission, or a pain-free period, that typically lasts 3 months or more.

Chronic cluster headaches. These attacks go on regularly for more than a year without a break.

You get a cluster headache when a nerve pathway in the base of your brain is triggered. That signal seems to come from a deeper part of the brain called the hypothalamus, home of the "internal biological clock" that controls your sleep and wake cycles.

The nerve that's affected, the trigeminal nerve, is responsible for sensations such as heat or pain in your face. It's near your eye and branches up to your forehead, across your cheek, down your jaw, and above your ear on the same side.

There are a few things that set this type of headache apart. They include:

Speed. Cluster headaches come on quickly, often with no warning.

Pain. It's often described as a burning or piercing feeling. It may be throbbing or constant. You'll feel it behind or around one eye. It may spread to your forehead, temple, nose, cheek, or upper gum on that side. Your scalp may be tender. You can often feel your blood pulsing.

Short duration. Cluster headaches can be as short as 15 minutes or as long as 3 hours, but then they disappear.

Predictable. Attacks seem to be linked to the circadian rhythm, your body's 24-hour clock. They tend to happen at the same time every day.

Frequent. Most people will get daily headaches -- sometimes several times a day. 

One-sided pain. Cluster headaches typically strike on one side of the face and head. The areas where you’re most likely to feel severe pain are behind or above an eye, or the side of your head behind an ear.

Restlessness and agitation. It’s common to feel restless and agitated during an attack. Unable to sit still, you may pace around the room or rock back and forth to ease the excruciating pain.

Experts aren't sure what causes cluster headaches. There’s evidence of a link to the hypothalamus, an area deep in your brain that controls things such as your body temperature, heart rate, and sleep cycles.

Researchers do believe that the activation of a key "pathway" nerve is how the severe pain travels behind your eye, to your forehead, and jaw — all on one side of your face.

The causes of cluster headaches aren't well understood, but experts are aware of some factors that can increase your risk of getting them:

Gender. Men are three to four times more likely than women to get cluster headaches. 

Age. You may be more at risk if you are between the ages of 20 and 40.

Family history. Cluster headaches often run in families, so if your parent or sibling suffers from them, you may be at risk too.

Tobacco use. Smoking has been strongly linked to a greater risk of cluster headaches.

Alcohol. Drinking alcohol, especially red wine and beer, are common triggers of cluster headaches.

Coffee. Some studies suggest a connection between how much coffee you drink and cluster headaches.

Head injury. Many people struggling with cluster headaches have a history of traumatic brain injury.

The pain usually starts suddenly, often around or behind the eye. You may notice:

  • Discomfort or a mild burning feeling 
  • A swollen or drooping eye
  • A smaller pupil in the eye
  • Eye redness or watering
  • Runny or congested nose
  • Red, warm face
  • Sweating
  • Sensitivity to light
  • Restlessness or agitation, pacing

How painful are cluster headaches?

Cluster headaches are often referred to as "suicide headaches" because they are so incredibly painful. The intensity of the pain has been compared to passing a kidney stone, or even childbirth. An attack can be unbearable, keeping you from work, school, or any of your regular activities.

When you’re in a cluster period, any of these can bring on a headache:

  • Cigarette smoke
  • Alcohol
  • Strong smells
  • Change to a high altitude
  • Bright light
  • Exercise or other vigorous activity
  • Being hot
  • Foods with nitrates, such as bacon or lunch meat
  • Cocaine

Both types of headaches cause intense pain. But the way they hurt and where you feel them are different.

Duration. Each cluster headache attack usually lasts 30-45 minutes, while a migraine can linger for an entire day.

Frequency. It’s possible to have as many as eight cluster headache attacks a day, while more than one migraine within 24 hours is unusual. Cluster headaches are much rarer than migraines.

Pain location. Cluster headaches happen on one side of your face, usually around the eye and temple. Migraine pain can be felt anywhere around your head.

Reaction to pain. A cluster headache typically leads to agitation and restlessness. That’s in sharp contrast to people with migraine, who prefer to sit still in a quiet, dark room.

Symptoms. A droopy eyelid, forehead sweating, and pupil changes are signs of a cluster headache. Migraines can lead to nausea, vomiting, and weakness.

Some symptoms shared between cluster headaches and migraines include:

  • Tearing
  • Eye irritation
  • Nasal congestion

Your doctor will make a diagnosis based on several factors:

  • Medical history
  • Pain intensity
  • How long each attack lasts
  • Physical/neurological exams

Your doctor may suggest diagnostic tests to rule out other causes of the pain. These may include:

MRI scan. This test uses radio waves to produce clear images of your brain and blood vessels.

CT scan. A CT scan takes detailed, 3D images of your brain as the X-ray machine revolves around your head.

You have several options when it comes to treating cluster headaches:

Medications

These medicines can help when the headache hits:

Triptans. These medicines are given as a shot. They can also be inhaled, but they don't work as quickly that way:

  • Sumatriptan (Imitrex)
  • Zolmitriptan (Zomig)

Dihydroergotamine (DHE 45). This prescription medicine can be given through a vein or inhaled. The inhaled version isn't proven to work for cluster headaches.

Octreotide. This is a lab-made form of somatostatin, a growth hormone. It's given as a shot.

Lidocaine. This is a pain reliever, in the form of a nasal spray.

Oxygen. Breathing in pure oxygen through a mask helps most people within 15 minutes. 

Preventive medicine can often stop a headache before it starts. Your doctor can prescribe medication to make a cluster headache shorter and less severe, including:

  • Calcium channel blockers (Calan SR, Verelan)
  • Corticosteroids such as prednisone
  • Divalproex sodium (Depakote)
  • Galcanezumab (Emgality)
  • Lithium carbonate

Occipital nerve block. The doctor will inject a mix of anesthetic and steroids into these nerves. They’re at the base of your skull, and they’re often the starting point for headaches. This is a temporary treatment until a preventive can start to work.

Nerve stimulation. If medication doesn’t work, some people have success with:

  • Occipital nerve stimulation.Your doctor surgically implants a device that sends electrical impulses to this group of nerves at the base of your skull.
  • Neuromodulation. These FDA-approved noninvasive devices include:
    • Cefaly. You put electrodes on your forehead and connect them to a headband-like controller that sends signals to your supraorbital nerve.
    • GammaCore. This gadget, also known as a noninvasive vagus nerve stimulator (nVNS), uses electrodes to send signals to this nerve.

Treatment at home. Things you can do at home to ease the pain include:

  • Wrap an ice or cold pack in a thin cloth and place it on the area for 10 to 20 minutes at a time. 
  • Take over-the-counter pain medicines such as acetaminophen or ibuprofen, if your doctor recommends them.
  • Do breathing exercises to calm your nervous system.

Surgery

If nothing else works, surgery may be an option for people who don't get a break from cluster headaches.

Most procedures involve blocking the trigeminal nerve, a main pathway for pain. It controls the area around your eye, but a misstep can lead to weakness in your jaw and loss of sensation in your face and head.

Talk to your doctor about:

  • Capsaicin. A nasal spray of this natural pain reliever from chili peppers might help.
  • Melatonin. This medication, known for easing sleep problems such as jet lag, might lower the number of headaches.

Breathing exercises

Breathing exercises have real effects on your body that help keep you calm and control your stress. They won't work on their own to relieve cluster headache pain, but they can help you remain calmer during an attack.

You can try different types of breathing. No matter which one you use, it helps to:

  • Find a quiet space where you won't be bothered.
  • Sit down and get comfy.
  • Let go of your worries for a few minutes.

It's also best to set aside time for it each day. This regular practice will train your body to fall into breathing more easily when you need it. If you do it only when you're in pain, it'll be much harder to really sink into it.

Deep breathing. When you're stressed and anxious, you tend to take shorter breaths than usual. This exercise helps you reset. The aim is to take slow, deep, and steady breaths:

  • Put your focus on your belly button. You might want to put a hand there to help.
  • As you breathe in through your nose, pull the air into your belly. Feel it expand as you fill up your lungs.
  • Breathe out through your nose with a long, slow breath. Pull your belly in as you empty out your lungs. You can even think to yourself, "Relax."

With each full, deep breath, your nervous system takes it down a notch.

Rhythmic breathing. If your breathing style is usually short and fast, this exercise will help you slow it down a bit:

  • Breathe in slowly through your nose as you count to five.
  • Breathe out slowly through your nose as you count to five.
  • Repeat and see if you can feel yourself relax with each breath.

As you notice yourself getting calmer, you give your body feedback that helps you relax even further.

Visualized breathing. For this one, you combine breathing with pictures in your mind:

  • Get comfortable, close your eyes, and breathe normally.
  • As you breathe in through your nose, picture calming air that fills up your lungs and expands your chest and belly. Imagine you're breathing in more and more relaxation.
  • As you breathe out, picture pushing the tension out right along with your breath.
  • Repeat, breathing in calm and out tension.

If you have cluster headaches, you might worry that they can lead to more serious health complications. But, as painful as they are, they're not life-threatening and don't cause brain damage.

Cluster headaches and mental health

Researchers have found evidence of a link between cluster headaches, bouts of depression, and anxiety. Attacks can disrupt your life, bring on feelings of hopelessness, and in some cases, suicidal thoughts.

One study showed that 92% of cluster headache patients also suffered from other chronic illnesses, including depression.

Sleep disorders

There appears to be a strong link between cluster headaches and sleep disorders. Attacks usually happen in similar patterns during sleep and are connected to your body’s internal clock. Experts say cluster headaches are associated with several sleep disorders. Among them are:

  • Sleep apnea
  • Insomnia
  • Narcolepsy

Cluster headaches are extremely disruptive. They can impact you, your family and your career. But there are ways to help cope with and limit attacks. You can:

  • Talk to a counselor or therapist.
  • Contact a headache support group.
  • Avoid things that can trigger your attacks, such as alcohol, smoking, or certain foods.
  • Find ways to reduce stress, such as meditation, yoga, or breathing exercises.
  • Discuss your condition with your boss. You may be able to work out a flexible schedule that helps you better manage your workload and stress level.

While dealing with cluster headaches is challenging, there are things you can do to reduce the number of attacks and the severity of them. Communication with your doctor is key. By keeping a detailed headache journal and having open and honest discussions, your health care provider can prescribe the best path forward for you.