Cluster and Facial Headache

Authors: Robert G. Kaniecki
Source: Orofacial Disorders, 8 July 2017, pp 257-267


  • Trigeminal autonomic cephalalgias (TACs) are primary headache disorders characterized by unilateral head pain of varying duration associated with ipsilateral cranial autonomic features.

  • TACs differ primarily in episode duration, frequency, and periodicity.

  • Cluster headache and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) are more common among men, while chronic paroxysmal hemicrania (CPH) and hemicrania continua (HC) among women.

  • The duration of headache attacks (15–180 min) helps differentiate cluster headache from the other TACs and also from migraine headache (4–72 h).

  • SUNCT is best differentiated from trigeminal neuralgia (TN) by location of pain (V1 versus V2–V3 for TN) and the prominent ipsilateral autonomic features (rare in TN).

  • Cerebral blood flow studies reveal hyperactivation of the hypothalamus ipsilateral to the pain in cluster headache, contralateral to the pain in CPH and HC, and bilateral in SUNCT.

  • Oxygen therapy and subcutaneous sumatriptan are the agents of choice for the treatment of acute attacks of cluster headache.

  • Prevention of cluster headache is most frequently accomplished with short-term corticosteroids and long-term verapamil. Electrocardiographic monitoring is necessary for those patients with cluster headache requiring verapamil doses greater than 240 mg.

  • Paroxysmal hemicrania and hemicrania continua are prevented absolutely by therapeutic doses of indomethacin. Co-administration of a proton pump inhibitor may improve the tolerability of long-term indomethacin dosing.

  • SUNCT is the most brief, least common, and most refractory TAC. Lamotrigine is the treatment of choice.

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