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Sometimes known as toxic or histamine headache, a cluster headache is still considered a vascular headache. Most patients describe cluster headaches as very severe and debilitating. The onset of a cluster headache may be gradual, with discomfort over one eye that spreads rapidly to the same side of the face. Typical onset is 2 to 15 minutes to peak intensity and is generally without warning. The pain, which is described as deep within the head, is not pounding in nature, but rather explosive in quality. It is not uncommon for a patient suffering from a cluster headache to say it is “like an ice-pick in my head.”

Duration of a cluster headache is generally 10–45 minutes; however, it can last up to four hours. The cluster headache gets its name from the “clusters” or frequent reoccurring periods in which the headache takes place.

Many individuals who suffer from cluster headache will experience one or two cluster periods a year. These periods often last two to three months each and seem to be more common in the spring and fall seasons. The headache may occur once to several times a day, generally coming on at the same time each day, i.e., “cluster times.”

Cluster headaches may begin at any time of life, but usually appear sometime in the early 20s to early 40s. They are more commonly associated with men than women. Cluster headache sufferers often have hazel-colored eyes, and are heavy smokers and drinkers. It is interesting to note that although the nicotine in cigarettes causes vascular constriction and alcohol causes vascular dilation, both substances may trigger cluster headaches.

Unless newly diagnosed, patients with a history of cluster headache will have explored a number of treatment options with their physician in order to find one or a combination of treatments that work best for them. Many of the medications are similar to the treatment options for migraine, and ergotamine preparations; oral analgesics, typically NSAIDs or a narcotic like codeine; corticosteroids, such as prednisone; and antidepressants like lithium have been shown to be very effective. Often, this treatment may be combined with ergotamine.

Intranasal lidocaine drops have also been effective in aborting cluster headaches in a large percentage of patients. The administration of lidocaine is believed to be effective because of its anesthetizing properties on nerves. Specifically, it has found success in headaches (migraine and cluster) where the trigeminal nerve acts as a motor pathway for pain, causing headache. The ability of medication to block the terminals of both the trigeminal and glossopharyngeal nerves has been identified as an extremely useful and minimally invasive therapy.

Not all patients respond to medical intervention for treatment of their cluster headache. To gain control over the headache and become free from its crippling pain, some individuals seek a more invasive, or even surgical, remedy. These interventions range from injections into the trigeminal nerve to use of radio frequency to disrupt nerve function, and, in some instances, cutting the nerve or branch of the nerve to stop the pain impulses.

For EMS providers called to a patient experiencing severe headache, there are some physical presentations that may clue you in to the cluster headache. The patient will describe the pain as starting around or behind one eye, which will be tearing (lacrimation), and the nares on the same side will either be blocked or runny (rhinorrhea). The affected eye will be injected (red), and the soft tissue around the eye will be swollen much of the time. In some individuals, the physical signs are so pronounced that one can literally draw a line down a patient’s face and see the signs on one side but not the other. The patient may be pale and diaphoretic, and may complain of scalp or facial tenderness. It is not unusual for these patients to also present with mild bradycardia.

Your first impression of a patient experiencing a cluster headache is that this patient is in real distress. The patient may try lowering his head to find a position of comfort; for some, physical exertion may provide relief from the pain. These patients may have a difficult time sitting still for your assessment. Because of the severity of pain, some patients may even verbalize a suicide threat.

A number of patients respond very favorably to high-concentration oxygen. O2 delivered via mask at 15 liters/minute for 5–15 minutes may actually prevent the cluster headache from getting worse. The sooner oxygen is started, the greater the chance for breaking the headache. Many patients with a history of cluster headache actually carry their own portable oxygen for rapid treatment at the first sign of headache.

When responding to a patient suffering a cluster headache, an organized approach to assessment is key to not overlooking patient signs or symptoms. Usual treatment includes establishing an IV of normal saline at a TKO rate; oxygen, if not already on the patient; and safe transport, allowing the patient to be in a position of comfort, if possible. Keeping interior lights at a low level and abstaining from using the siren will go a long way toward patient comfort. You can also offer a cold pack and allow the patient to put it where he believes it will help the most. Medication that could be beneficial to the patient would include calcium channel blockers, such as verapamil (Calan) and antiemetics like prochlorperazine (Compazine). Consult with online medical direction, since this is most likely outside your usual EMS system protocols.

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