Migraine vs Cluster headache
How to tell Migraine and Cluster headache apart when a board question makes them look alike.
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Attack duration with autonomic signs separates them: 15 to 180 minute unilateral orbital attacks with ipsilateral tearing point to cluster headache.
Side by side
Recurrent unilateral throbbing headache lasting hours with nausea, photophobia, and preference to lie still in a dark room supports migraine.
Brief attacks of excruciating unilateral orbital pain with ipsilateral tearing or rhinorrhea and marked restlessness support cluster headache.
Trigeminovascular activation with neurogenic inflammation drives episodic migraine pain and sensory hypersensitivity.
Hypothalamic trigeminal autonomic activation triggers short severe periorbital attacks with cranial autonomic discharge.
ICHD-3 pattern: at least 5 attacks lasting 4 to 72 hours with at least 2 pain features (unilateral, pulsating, moderate to severe, worse with activity) plus nausea or photophobia and phonophobia; neurologic exam and brain imaging are typically normal when no red flags are present.
ICHD-3 pattern: at least 5 attacks of severe unilateral orbital or temporal pain lasting 15 to 180 minutes, occurring from every other day up to 8 per day, with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, ptosis, or agitation.
The trap
A common miss is treating cluster headache like migraine and delaying abortive oxygen. The resolving clue is pacing and agitation during short attacks with ipsilateral tearing, while migraine patients usually avoid movement and seek quiet darkness.
The repair move
Next best step: start 100% oxygen by nonrebreather mask at 12 to 15 L/min and give subcutaneous sumatriptan 6 mg for acute cluster attacks, then begin verapamil prophylaxis with ECG monitoring for PR prolongation.
Try a free question
CoreA 29-year-old man has 3 weeks of daily unilateral right orbital headaches lasting about 45 minutes with ipsilateral tearing and nasal congestion. He paces during attacks. What is the most likely diagnosis?
Show answer and explanation
Answer: A. Cluster headache. Short recurrent unilateral orbital pain with cranial autonomic symptoms and agitation is classic for cluster headache.
Why the other choices are tempting
- B. Wrong because migraine usually lasts hours, often has nausea and photophobia, and patients prefer to rest quietly rather than pace.
- C. Wrong because tension headache is typically bilateral pressing pain without autonomic eye or nasal features.
- D. Wrong because temporal arteritis usually occurs after age 50 with jaw claudication and high ESR, not brief repetitive attacks.
- E. Wrong because subarachnoid hemorrhage presents as sudden thunderclap headache with persistent severe symptoms, not stereotyped short attacks over weeks.
Flashcards
Tap a card to flip it.
What bedside behavior during a unilateral severe headache favors cluster headache over migraine?
Marked restlessness or pacing during the attack favors cluster headache, whereas migraine patients usually lie still.
How does typical attack duration distinguish migraine from cluster headache?
Migraine usually lasts 4 to 72 hours, while cluster headache lasts 15 to 180 minutes.
Quick answers
What is the fastest way to tell Migraine from Cluster headache?
Attack duration with autonomic signs separates them: 15 to 180 minute unilateral orbital attacks with ipsilateral tearing point to cluster headache.
What is the key clue for Migraine?
Recurrent unilateral throbbing headache lasting hours with nausea, photophobia, and preference to lie still in a dark room supports migraine.
What is the key clue for Cluster headache?
Brief attacks of excruciating unilateral orbital pain with ipsilateral tearing or rhinorrhea and marked restlessness support cluster headache.
What is the common trap with Migraine vs Cluster headache?
A common miss is treating cluster headache like migraine and delaying abortive oxygen. The resolving clue is pacing and agitation during short attacks with ipsilateral tearing, while migraine patients usually avoid movement and seek quiet darkness.