The distinction between migraines and cluster headaches is often simple: Migraines send people to the darkest, quietest corner they can find to soothe their heightened sensitivity to light and sound, whereas cluster headaches typically announce themselves with a far more acute kind of pain. “Somebody who paces the room during their headache and bangs their head against the wall or the floor because it’s the worst pain they’ve ever felt—that’s cluster headache,” says Dr. Michael Oshinsky, director of the Office of Preclinical Pain Research at the National Institute of Neurological Disorders and Stroke.
That’s no exaggeration—some experts have described that pain as among the worst known to humankind. But what actually is a cluster headache? The condition is part of a family of disorders known as trigeminal autonomic cephalalgias, which result from dysfunctions of the hypothalamus—an almond-sized chunk of nuclei that regulates bodily operations like circadian rhythms and thirst, as well as the systems in your brain connecting nerves and feeling to your face. That’s why cluster headaches often flood the front of the head, causing red eyes, drooping eyelids, tearing, and runny nose.
A single cluster headache can be as short as 15 minutes, or stretch on for three hours. The flashes of excruciating pain often occur in quick succession—hence the name cluster. Because the disorder is relatively rare, affecting roughly one in a thousand people, it hasn’t yet drawn the full attention of the medical industry. “We do have treatments for them,” says Dr. Oshinsky, “but many, many fewer options” than those available for migraines.
As with migraines, those treatments include both preventative steps a patient can regularly take in anticipation of symptoms and acute measures patients can take in response to an emerging episode.
On the preventive side, great strides in migraine-prevention research have yielded a new generation of drugs that are also effective treatments for cluster headaches. Targeting a protein in the nervous system called calcitonin gene-related peptide (CGRP) that increases in number during headaches, these drugs, known as CGRP receptor agonists, are primarily used to treat migraines; only one of them, galcanezumab, has been approved by the FDA for the prevention of cluster headaches. Other options include lithium, anti-hypertensive drugs, anticonvulsants, and antidepressants.
The acute treatment of cluster headaches is also informed by migraine medication. Triptans, a type of drug that binds to serotonin receptors and helps prevent them from painfully dilating during migraine episodes, have proven effective treatments for both migraine and cluster headache patients. One challenge for the acute treatment of cluster headaches is finding a remedy that takes effect in time, as cluster attacks can be as brief and they are painful, so speedy treatment is essential. According to Dr. Teshamae Monteith, Associate Professor of Clinical Neurology and Chief of the Headache Division at UHealth, The University of Miami Health System, patients benefit more from triptans administered by injection or as a nasal spray than they do from tablets, which are slower to take effect.
Due to headache medicine’s relatively recent history and the limited profit opportunity for the pharmaceutical industry, cluster headaches are just one of a host of conditions that have a short treatment list. Other lesser-known headache disorders that deserve more medical attention include new daily persistent headache, thunderclap headache, medication overuse headache, chronic migraine, and headache associated with sexual or physical activity. “Anybody who gets regular headaches, more than one or two a month, should speak to their physician about it,” says Dr. Oshinsky. “They will benefit from that conversation.”
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