Clinical Characteristics of Cluster Headache Attacks Vary Considerably

man holding his head with a red spot indicating a cluster headache
man holding his head with a red spot indicating a cluster headache
Researchers found data from a case study over a 6-year-period that shows for chronic cluster headache, the use of a smartphone application to collect data revealed that diurnal rhythmicity changed over time with headache severity at night; pain severity and the amount of cranial autonomic symptoms duration increased concurrently; and a remission pattern was found.

Clinical characteristics of cluster headaches (CH) display a high degree of intrapatient variation, according to a study published in Cephalalgia.

In this case report of a man aged 34 years suffering from chronic cluster headaches without prior history of serious head trauma or neurological disease, investigators collected data using a dedicated smartphone application (My Headache Log Pro, by Solar Embedded). The data included time, duration, maximum pain severity indicated on a numeric rating scale (NRS) scoring pain from 1 to 10, location when having a cluster headache attack, cranial autonomic symptoms, restlessness/agitation, mild pain in the area after the attack, and treatment. Cluster headache attacks were divided into 4 categories of severity: mild (NRS 1-2), moderate (NRS 3-4), severe (NRS 5-6), and very severe (NRS 7+). Prior to collection of case data, the patient was treated with prophylactic treatments of verapamil (maximum dose of 400 mg). The treatment had a substantial effect on pain intensity, but not attack frequency, so it was discontinued due to nightmares and disturbed sleep.

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A total of 4600 cluster headache attacks were recorded between April 2011 and November 2017. The mean severity score was 3.6, duration was 39.3 (SD 18.5) minutes, and daily frequency was 1.9 per day (SD 1.3). The duration of the attack and the likelihood of cranial autonomic symptoms increased with the severity of the attacks. The patient registered having mild pain prior to 96.4% of moderate, severe, and very severe attacks. Acute treatment with oxygen was registered in 23.8% of mild attacks, 77.2% of moderate attacks, 94.7% of severe attacks, and 96.9% of very severe attacks. Cluster headache attacks were more severe at night than during daytime hours, although the duration of attacks had no obvious difference when occurring at night vs in the daytime. No observable monthly patterns of higher or lower frequency of attacks were found throughout the year.

The purpose of this case report was for the researchers to generate a hypotheses.

Along with the recorded simultaneous increasing pain severity, the number of cranial autonomic symptoms, and duration of attacks, mild attacks of cluster headaches are an indicator of cluster headache activity and may constitute a cluster headache disease phenomenon that is self-limiting in nature and worthy of further investigation. In applying chronorisk analysis in the personalized treatment of patients with cluster headaches, “the evolution of chronorisk patterns over time suggests that continuous, cluster-wise, evaluation of rhythmicity may be necessary.” The researchers believe that this case demonstrates that digitizing headache diary registration by smartphone applications is feasible and would provide a great deal of detailed clinical data. 


Hagedorn A, Snoer A, Jensen R, Haddock B, Barloese M. The spectrum of cluster headache: A case report of 4600 attacks [published online March 26, 2019]. Cephalalgia. doi: 10.1177/0333102419833081