Verapamil first-line preventive in guideline consensus
ECG monitoring required due to conduction risk
Dose titration often necessary
Corticosteroid bridge supported by expert consensus
Short-term reduction in attack frequency
Not a long-term preventive
Emergency medicine policy mapping
ACEP clinical policy structure applied to acute headache evaluation
Level B for imaging when red flags present
Level C for shared decision-making when low-risk presentation
Cardiology style recommendation mapping
Class I style recommendation for oxygen and triptan as first-line abortive in typical cluster without contraindications
Based on specialist guideline consensus
Patient-specific risk screening required
Class IIa style recommendation for occipital nerve block as transitional therapy
Useful when systemic steroids undesirable
Procedure availability dependent
Pregnancy
Pregnancy considerations
Diagnostic approach
Low threshold secondary cause evaluation in pregnancy and postpartum
MRI preferred when imaging needed and feasible
Abortive therapy safety
Oxygen generally preferred
Triptan risk-benefit individualized and protocol-dependent
Preventive and bridge therapy cautions
Verapamil use requires maternal ECG considerations
Corticosteroid short course risk-benefit individualized
Geriatric
Older adult considerations
Secondary cause prevalence higher
Imaging threshold lower for new cluster-like headache
Giant cell arteritis screening when appropriate
Medication risk
Triptan cardiovascular contraindications more common
Verapamil conduction disease and polypharmacy interactions
Disposition planning
Falls risk with hypotension from verapamil
Close follow-up for medication titration
Pediatrics
Pediatric considerations
Diagnostic confidence
Cluster headache rare in children
Secondary cause evaluation threshold lower
Treatment adaptation
Oxygen as preferred abortive when diagnosis confident
Triptan dosing and age approvals protocol-dependent
Specialist coordination
Pediatric neurology involvement early
School and sleep disruption planning
Epidemiology
Frequency and demographics
Relative rarity compared with migraine
Often underdiagnosed or misdiagnosed
Delay to diagnosis common
Sex distribution
Male predominance reported in many cohorts
Female cases under-recognized risk
Typical age of onset
Early adulthood common
Late onset prompts secondary evaluation
Pathophysiology
Trigeminal autonomic reflex activation
Trigeminal nociceptive pathways
Severe orbital and temporal pain pathway
Trigeminal distribution localization
Parasympathetic outflow via sphenopalatine ganglion
Lacrimation and nasal congestion
Conjunctival injection
Sympathetic dysfunction
Partial Horner syndrome features
Ptosis and miosis on affected side
Hypothalamic involvement
Circadian and circannual periodicity
Attacks at consistent times
Bout seasonality
Sleep relationship
Nocturnal attacks
REM association hypothesis
Therapeutic Considerations
Oxygen mechanism rationale
Cerebral vasoconstriction and neurochemical modulation hypotheses
Rapid symptomatic relief pathway
Minimal systemic adverse effects
Delivery and flow importance
High inspired oxygen fraction requirement
Early initiation improves response
Triptan mechanism rationale
Serotonin receptor agonism
Trigeminal pathway modulation
Neurogenic inflammation reduction
Route selection rationale
Subcutaneous fastest onset
Intranasal alternative when injection not feasible
Preventive rationale
Verapamil calcium channel blockade
Attack frequency reduction in many patients
Dose-response with monitoring constraints
Transitional therapy bridge
Steroid short course to suppress attacks
Preventive onset delay coverage
copy discharge instructions
Discharge instructions
Diagnosis explanation
Cluster headache pattern with severe one-sided attacks and tearing or nasal symptoms
Bouts can last weeks to months with multiple attacks per day
Home abortive plan
Oxygen use plan if prescribed
Triptan use plan if prescribed and safe
Trigger avoidance during bout
Alcohol avoidance during active cluster period
Strong odor and solvent avoidance when possible
Preventive and bridge plan
Verapamil schedule and ECG monitoring plan if started
Steroid taper instructions if prescribed
Return now or call emergency services
Sudden worst headache of life or thunderclap onset
Weakness, numbness, speech trouble, confusion, fainting, or seizure
Fever with stiff neck
Eye pain with vision loss or new severe redness
New headache pattern after age 50
Follow-up
Neurology or headache clinic appointment timing
Primary care review for cardiovascular risk and medication safety
Safety and support
Severe distress or inability to cope
Seek immediate help from trusted adult or local emergency services
Clinical guidelines and consensus sources
Guideline sources
International Classification of Headache Disorders, 3rd edition diagnostic criteria
Cluster headache diagnostic criteria
Episodic and chronic cluster definitions
American Headache Society guidance on cluster headache management
High-flow oxygen as first-line abortive
Subcutaneous sumatriptan as first-line abortive
European Headache Federation guidance on trigeminal autonomic cephalalgias
Verapamil as first-line preventive
Transitional steroid and occipital nerve block options
Emergency medicine policy sources
ACEP clinical policy framework for acute headache evaluation
Imaging triggers for red flag features
Risk stratification principles for secondary headache
Evidence-based sources and key therapies
Therapy evidence anchors
Oxygen trials and observational evidence base
Rapid relief compared with room air in many patients
Optimal delivery with high flow and non-rebreather
Triptan clinical trial evidence base
Subcutaneous sumatriptan rapid efficacy
Intranasal zolmitriptan efficacy as alternative
Preventive therapy evidence base
Verapamil dose titration with ECG monitoring necessity
Lithium and topiramate as alternatives when verapamil insufficient
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.