Migraine vs cluster headache: how the attacks differ

Think of migraine as the common, slow-building, whole-body attack and cluster headache as the rare, abrupt, one-sided attack that makes people unable to sit still. Migraine often comes with nausea and sensitivity to light and sound, and a person typically retreats to a quiet, dark room. Cluster headache is described as one of the most painful conditions a person can have, and sufferers often pace or rock.

The NHS notes that cluster headaches are rare but some of their symptoms can be the same as other conditions such as migraine. Because treatment is so different, the distinction matters and is worth raising with a GP.

The NHS describes a migraine attack as a throbbing headache that can be severe, often on one side and worse when moving around, with feeling or being sick and sensitivity to light and sounds. Some people get warning signs such as zigzag lines, flashing lights, tingling or difficulty speaking, and early symptoms like tiredness, mood changes and yawning can start hours or even up to 2 days before the head pain.

A cluster headache is different in tempo. The NHS describes a sharp, burning or piercing pain, usually on one side around the eye, which starts and stops quickly without warning and lasts between 15 minutes and 3 hours. The Migraine Trust says it comes on very quickly, usually behind or around the eye, can occur at the same time every night and usually ends suddenly, leaving people pain free but exhausted. Some people do experience nausea and sensitivity to light, and aura is rare.

Cluster headache is named for its pattern. The Migraine Trust says people have bouts of frequent attacks (cluster periods) that last from weeks to months, followed by remission for months or even years. During a bout, attacks may occur daily, or many times a day, and often at the same time each day or at the same time each year, commonly spring or autumn. It can be episodic or chronic, with up to 2 in 10 people having the chronic form without remission.

Migraine does not follow this bout-and-remission pattern. The Migraine Trust describes episodic migraine as headache and migraine symptoms on fewer than 15 days a month, and chronic migraine as headache on at least 15 days a month, with migraine symptoms on at least eight of those, for three months or more. Menstrual migraines linked to periods are common and are often longer and more severe, the NHS says.

There are no specific tests to diagnose cluster headaches, according to the NHS. A GP asks about the location, frequency and timing of the pain and other symptoms. The Migraine Trust says the doctor will make a diagnosis from the history and a neurological examination, and may arrange a brain scan to rule out a secondary cause. People with cluster headache are often referred to a neurologist or headache specialist. A headache diary is useful for both conditions.

For migraine, the NHS lists painkillers taken as soon as the headache starts, triptans and gepants, and anti-sickness medicines, with prevention including beta blockers, antidepressants, epilepsy medicines, acupuncture, relaxation, CBT and vitamin B2.

For cluster headache, the NHS says painkillers such as paracetamol and ibuprofen do not work. Treatments during an attack include triptans given as an injection or nasal spray, oxygen breathed through a mask, and a device that gives mild electrical pulses to the back of the neck. The NHS says a GP may prescribe corticosteroids, verapamil or lithium to prevent attacks, and the Migraine Trust says verapamil is the preventive treatment of choice and needs regular ECG monitoring. These are specialist decisions.

The NHS says to call 999 or go to A&E if you have a drooping eyelid or one pupil smaller than the other for the first time, even if cluster headaches are already diagnosed. It also advises an urgent GP appointment or NHS 111 for a severe headache with jaw pain when eating, blurred or double vision, a sore scalp or numbness or weakness, which could be signs of temporal arteritis. A sudden, extremely painful headache needs 999.