History

Fact Explanation
Episodic headache (occurring in clusters). Symptoms occur repeatedly for a few weeks, followed by a symptom free period of a few months before another cluster occurs; thus differentiating it from migraine which is also unilateral. [1]
Severe, unilateral periorbital pain, which is boring in character. Due to trigeminal nerve involvement. [2]
Episodes are characteristically brief (30-90 minutes). Characterized by recurrent attacks that last 15 to 180 minutes and are recurrent (1 every other day to 8 per day). [3]
Symptoms present at determined hours, and are commonly nocturnal. There's evidence pointing to Hypothalamic involvement; the Hypothalamus predominantly participates in regulation of several biological and specifically circadian cycles. [3]
Patients are quite restless at the time of the attack. This symptom differentiates cluster headache from migraine where the patient prefers a calm and quiet environment. [4]
Commonly associated with ipsilateral conjunctival injection, lacrimation, rhinorrhoea and nasal congestion. Due to autonomic nervous system dysfunction. [3]
References
  1. LINDE Klaus et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews [online]. 2009, Issue 1. Art. No.: CD001218. [viewed 1 March 2014] Available from: DOI: 10.1002/14651858.CD001218.pub2
  2. LAW Simon, Sheena DERRY and R Andrew MOORE. Triptans for acute cluster headache. Cochrane Database of Systematic Reviews[online]. July 2013, Issue 7. Art. No.: CD008042. [viewed 1 March 2014] Available from: DOI: 10.1002/14651858.CD008042.pub3.
  3. LEROUX Elizabeth Leroux, DUCROS Anne. Orphanet Journal of Rare Diseases [Online] 2008, 3:20. [Viewed 25 April 2014]. Available from: doi:10.1186/1750-1172-3-20
  4. ROZEN T. D. et al. Cluster headache in women: clinical characteristics and comparison with cluster headache in men. Journal Neurology Neurosurgery and Psychiatry [online]. 2001, vol 70. 613-617 [viewed 1 March 2014] Available from: doi:10.1136/jnnp.70.5.613
  5. BAHRA Anish, Arne MAY and P. J GOADSBY. Cluster headache: A prospective clinical study with diagnostic implications. Neurology [online]. February 2002, vol. 58 (3). 354-361 [viewed 1 March 2014] Available from: doi: 10.1212/WNL.58.3.354

Examination

Fact Explanation
Ipsilateral horner's syndrome at the time of an attack. Due to autonomic disturbance. [1]
Ipsilateral conjunctival injection and lacrimation during an attack. Due to autonomic disturbance. [1]
References
  1. ROZEN T. D. et al. Cluster headache in women: clinical characteristics and comparison with cluster headache in men. Journal Neurology Neurosurgery and Psychiatry [online]. 2001, vol 70:613-617 [viewed 1 March 2014] Available from: doi:10.1136/jnnp.70.5.613

Differential Diagnoses

Fact Explanation
Migraine It also tends to be unilateral but classical migraine is preceeded by an aura (fortification spectra in vision, flashes, etc). [1]
Acute angle-closure glaucoma Pain is ocular, as opposed to periorbital pain which is experienced in cluster headache. [2]
Giant cell arteritis Tenderness is experienced on palpation along the course of the superficial temporal artery. Jaw claudication is also present. [3] Note: This differential is an emergency where prompt diagnosis and treatment could prevent blindness.
References
  1. LAW Simon, Sheena DERRY and R Andrew MOORE. Sumatriptan plus naproxen for acute migraine attacks in adults. Cochrane Database of Systematic Reviews [online]. 2013, Issue 10. Art. No.: CD008541.[viewed 2 March 2014] Available from: DOI: 10.1002/14651858.CD008541.pub2.
  2. REDDY Aravind and Sandra M JOHNSON. Iridectomy or iridotomy for preventing angle-closure glaucoma (Protocol). Cochrane Database of Systematic Reviews [online]. 2007, Issue 4. Art. No.: CD006783. [viewed 2 March 2014] Available from: DOI: 10.1002/14651858.CD006783
  3. MOLLAN Susan P. et al. Aspirin as adjunctive treatment for giant cell arteritis (Protocol). Cochrane Database of Systematic Reviews [online] 2013, Issue 4. Art. No.: CD010453. [viewed 2 March 2014] Available from: DOI: 10.1002/14651858.CD010453

Investigations - for Diagnosis

Fact Explanation
Erythrocyte sedimentation rate (ESR) To exclude Giant Cell Arteritis, which is an emergency; a very high ESR would be suggestive of Giant Cell Arteritis. [1]
Tonometry This detects high intra-ocular pressures which occur in glaucoma. [2]
References
  1. HILL Catherine L et al. Steroid sparing drug treatments for giant cell arteritis (Protocol). Cochrane Database of Systematic Reviews [online] 2009, Issue 1. Art. No.: CD005323. [viewed 2 March 2014]. Available from: DOI: 10.1002/14651858.CD005323.pub2.
  2. ODDONE Francesco et al. Optic nerve head and fibre layer imaging for diagnosing glaucoma (Protocol). Cochrane Database of Systematic Reviews [online] 2010, Issue 11. Art. No.: CD008803. [viewed 2 March 2014]. Available from: DOI: 10.1002/14651858.CD008803.

Management - General Measures

Fact Explanation
Avoid triggers such as alcoholic beverages. Alcohol as well as other substances such as histamines and nitrates are known to trigger bouts of cluster headaches. [1]
Apply temporal pressure. [1] Gives symptomatic relief to the patient.
Apply heat to the eye. [1] GIves symptomatic relief to the patient.
References
  1. ROHKAMM, Reinhard. Color atlas of neurology. Translation revised by Ethan TAUB. New York: Thieme, 2004.

Management - Specific Treatments

Fact Explanation
100% oxygen. Oxygen has the ability to constrict distal cerebral resistance vessels. It can also act as a serotonergic agonist and an immunomodulator of substance P. [1]
Subcutaneous sumatriptan. Triptans act as serotoninergic receptor agonists and inhibit trigeminal nerve endings, thereby reducing the pain. [2]
References
  1. BENNETT Michael H. et al. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Cochrane Database of Systematic Reviews[online]. July 2008, Issue 3. Art. No.: CD005219. [viewed 1 March 2014]. Available from: DOI: 10.1002/14651858.CD005219.pub2.
  2. LAW Simon, Sheena DERRY and Andrew R MOORE. Triptans for acute cluster headache. Cochrane Database of Systematic Reviews[online]. July 2013, Issue 7. Art. No.: CD008042. [viewed 1 March 2014] Available from: DOI: 10.1002/14651858.CD008042.pub3.