Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 24-01: Headache + Key Features Download Section PDF Listen +++ ++ Affects mainly middle-aged men May relate to activation of cells in the ipsilateral hypothalamus, triggering the trigeminal autonomic vascular system There is often no family history of headache or migraine + Clinical Findings Download Section PDF Listen +++ ++ Severe unilateral periorbital pain occurring daily for several weeks Often accompanied by ipsilateral nasal congestion, rhinorrhea, redness of the eye, lacrimation, or Horner syndrome Episodes often occur at night and last for between 15 minutes and 3 hours During attacks, patients are often restless and agitated Precipitants of an attack Alcohol Stress Glare Specific foods Spontaneous remission occurs, and the patient remains well for weeks or months before another bout occurs Bouts may last 4–8 weeks and may occur up to several times per year Occasionally, remission does not occur; this variant is chronic cluster headache + Treatment Download Section PDF Listen +++ ++ Sumatriptan, 6 mg subcutaneously or 20-mg/spray intranasally, or inhalation of 100% oxygen (12–15 L/min for 15 min) may be effective Dihydroergotamine (0.5–1 mg intramuscularly or intravenously) is sometimes used Viscous lidocaine (1 mg of 4–6% solution) intranasally is sometimes effective For prophylaxis, give ergotamine tartrate as rectal suppositories (0.5–1.0 mg at night or twice daily), orally (2 mg once daily), or by subcutaneous injection (0.25 mg three times daily for 5 days per week) Other potentially helpful prophylactic agents include Lithium carbonate (start at 300 mg daily, titrating according to serum levels and treatment response up to a typical total daily dosage of 900–1200 mg divided 3–4 times) Verapamil (240–960 mg daily orally) Topiramate (100–400 mg daily orally) Ergotamine tartrate 0.5–1 mg rectally at night or twice daily 2 mg orally daily 0.25 mg subcutaneously three times daily for 5 days per week Civamide (zucapsaicin 50 mg solution for intranasal administration) (not FDA approved for use in the United States) Hemicrania continua completely resolves with indomethacin Electrical stimulation Stimulation of the vagus nerve at headache onset successfully aborts pain in 30–50% of attacks Twice daily prophylactic stimulation reduces attack number in chronic cluster headache Approved in the United States In Europe, sphenopalatine ganglion stimulation is approved for treatment of cluster headache based on efficacy in one randomized sham-controlled study Stimulation of the occipital nerve may be helpful