Cluster Headache

Procedure

During or soon after an attack (or from photos or the history), look for features on the side of the pain: watering eye, red eye, blocked or runny nose, drooping eyelid, small pupil, facial sweating and eyelid swelling.

Positive Finding

One or more of these features on the same side as the pain during attacks.

Interpretation

These features, with strictly one-sided, severe, short-lived attacks of pain around the eye and restlessness during attacks, are what defines cluster headache. A drooping eyelid with a small pupil that persists between attacks needs urgent imaging to rule out a carotid artery dissection or other cause. Autonomic features on the same side as the pain (tearing, red eye, blocked or runny nose, drooping eyelid, small pupil, facial sweating) are part of the definition of cluster headache in the International Classification of Headache Disorders. Measuring how often they are present in people diagnosed using those same features is circular, so no accuracy figure is shown. Autonomic features on the same side as the pain (tearing, red eye, blocked or runny nose, drooping eyelid, small pupil, facial sweating) are part of the definition of cluster headache in the International Classification of Headache Disorders. Measuring how often they are present in people diagnosed using those same features is circular, so no accuracy figure is shown.

Procedure

Gently palpate both temporal arteries in front of the ears and ask about scalp tenderness, jaw pain on chewing and visual symptoms.

Positive Finding

Tender, thickened or nodular temporal artery with a weak pulse.

Interpretation

The artery is normal in cluster headache. New headache with scalp tenderness, jaw pain on chewing or visual disturbance in someone over 50 suggests giant cell arteritis: same-day emergency assessment.

Procedure

Check active neck movement in all directions and screen the upper cervical spine for pain or headache reproduction.

Positive Finding

Restricted or painful neck movement, or headache reproduced from the neck.

Interpretation

Cluster headache does not come from the neck, so the neck examination is expected to be normal; abnormal findings point to another or additional cause. Cluster headache needs medical diagnosis and treatment (for example high-flow oxygen); manual therapy is not a treatment for the attacks.

Procedure

Test vision and visual fields, eye movements and pupils, facial sensation and jaw strength, facial movement, and hearing, comparing sides.

Positive Finding

Any deficit, especially persisting between attacks.

Interpretation

Should be normal between attacks. A deficit, or a first episode of cluster-like headache, needs medical assessment and imaging to rule out a secondary cause such as a pituitary or other lesion. Refer urgently for a new or changed headache with red flags: sudden severe onset, neurological signs, fever or neck stiffness, new headache after 50, headache worse lying down or on straining, or a history of cancer or immune suppression.

Procedure

Measure blood pressure and heart rate at rest, in both arms.

Positive Finding

Raised blood pressure, or a clear difference between arms.

Interpretation

Blood pressure and heart rate can rise during an attack. Very high blood pressure with a severe headache, or a large difference between the arms, needs same-day medical assessment.