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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
headache in adults age 18 years and older
diagnosis and assessment of headache, including a severity assessment of the possible causes
consideration of serious causes of headache, including:
giant cell arteritis (GCA)
primary angle closure glaucoma
benign intracranial hypertension
the care map will not cover the detailed management of the conditions above, but rather the urgent assessment and timely referral to secondary care for further investigation
diagnosis and management of primary headaches, including:
 International Headache Society (IHS). Headache Classification Subcommittee of the International Headache Society (IHS). Oxford: Blackwell Publishing; 2005.
 Clinical Knowledge Summaries (CKS). Migraine. Version 1.1. Newcastle upon Tyne: CKS; 2012.
 National Institute for Health and Clinical Excellence (NICE). Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. NICE technology appraisal guidance 260. London: NICE; 2012.
 Contributors representing the Royal College of Physicians. London: 2013.
Diagnosis table for tension-type headache, migraine and cluster headache from the NICE website (CG150) is attached.
Trigeminal autonomic cephalalgias (TACs) are rare and are characterised by short-lasting attacks of severe unilateral pain in a trigeminal distribution.
Cluster headache is by far the most common TAC, and is characterized by recurrent attacks of one-sided pain, in or around the eye or temporal region, and associated with signs of autonomic dysfunction on the same side [2,18].
Typical features of a cluster headache:
pain is defined as:
unilateral (around the eye, above the eye and along the side of the head/face) 
severe or very severe intensity [1,2]
variable quality (can be sharp, boring, burning, throbbing or tightening) 
rapid onset  and short-lasting, for 15-180 minutes  (typically 30-60 minutes) 
patient is restless during an attack 
headache commonly wakes the person from sleep within 2 hours of going to sleep, and may also occur at other times 
highly characteristic and strictly ipsilateral autonomic features, including any of the following :
red and/or watery eye
nasal congestion and/or runny nose
forehead and facial sweating
constricted pupil and/or drooping eyelid
may also be a continuous background headache 
often a striking circadian rhythm 
attacks may be associated with migrainous features such as photophobia, phonophobia, nausea, and vomiting 
some people may experience persistent mild background pain between attacks 
Cluster headache may be episodic or chronic:
episodic cluster headache
occurs in clusters (cluster periods) of frequent attacks 
frequency of attacks varies from one every other day to eight per day , with a remission period of more than one month 
chronic cluster headache
frequency of attacks varies from one every other day to eight per day , with a continuous remission period of less than one month in a 12-month period
A meta-analysis of studies on the prevalence of cluster headache worldwide found that:
approximately 1 in 1000 people have been diagnosed with cluster headache at some time in their life
approximately 1 in 2000 people have had an episode of cluster headache in the last 12 months
cluster headaches are four times more likely to occur in men than in women
episodic cluster headache is six times more common than chronic cluster headache
Differentiation from trigeminal neuralgia (TN) :
TN may coexist with cluster headache
pain duration of TN is brief (few seconds), distinguishing it from cluster headache
autonomic symptoms are not prominent in TN
Hemicrania continua :
is a persistent unilateral headache
responsive to indometacin
patient suffers headache for more 3 months which also fulfils the following criteria:
unilateral pain without side-shift
daily and continuous, without pain-free periods
moderate intensity, but with exacerbations of severe pain
at least one of the following autonomic features occurring during exacerbation and ipsilateral to the side of the pain:
conjunctival injection and/or lacrimation
nasal congestion and/or rhinorrhoea
ptosis and/or miosis
complete response to therapeutic dose of indometacin
Paroxysmal hemicrania :
are attacks with similar characteristics of pain and associated symptoms and signs to those of cluster headaches but are shorter-lasting, more frequent, occur more commonly in females and respond absolutely to indometacin
diagnostic criteria is at least 20 attacks fulfilling the following criteria:
attacks of severe unilateral orbital, supraorbital or temporal pain lasting 2-30 minutes
headache is accompanied by at least one of the following:
Treatment may also be carried out in primary care while awaiting referral .
a subcutaneous or nasal triptan  to be taken when required for treatment of acute attacks − especially useful to treat acute attacks that occur away from home when the patient does not have access to oxygen therapy , eg:
the most effective relief of acute attacks of cluster headache
can be used twice in one day if clinically appropriate
licensed for use in cluster headache 
ensure the patient is offered an adequate supply of triptans calculated according to their history of cluster bouts, based on the manufacturer's maximum daily dose 
If one triptan is ineffective patients may respond to an alternative non-oral triptan
Do not offer paracetamol, NSAIDS, opioids, ergots, or oral triptans for the acute treatment of cluster headache .
NB: Advise the patient to avoid drinking alcohol or inhaling volatile fumes from substances such as solvents or oil-based products, as these may trigger an attack during an active period of cluster headaches .
Local administrative information
All requests for Oxygen should go via Home Oxygen Service (HOS) Tel 01275 546555 8.30 - 16.30 Monday to Friday.
The HOS will assess (& review) the patients to see if oxygen therapy is likely to be beneficial. The HOS will order the oxygen (including setting the flow rate and the length of time to use it for. N.B. BNF states 100% oxygen 10-15litres for 10-20 minutes to abhort the attack).
Anecdotally cluster headaches usually occur in 'clusters' and patients can predict them coming. It may be appropriate in these patients to have speedy access to oxygen when they need it but then remove the cyclinders afterwards until the next attack. HOS will arrange this.
Please see the Oxygen initiation flowchart in the information node for both in hours and out of hours requests. It is unlikely an Out of Hours request would be needed for cluster headache. The related forms (Oxygen assessment referral form, Oxygen consent form (HOCF) and Oxygen order form (HOOF) can be accessed from the referral node on this care map.
Please note: Emergency HOOF (within 4 hours) costs £90.37 and is significantly more expensive than next day delivery.
The Home Oxygen referral form is available as an EMIS template