About cluster headache
Cluster headache vs migraine
Cluster headache is frequently misdiagnosed as migraine. They are both primary headache disorders, but they are fundamentally different conditions with different symptoms, different patterns and different treatments. Getting this right is critical.
Why the confusion exists
Both conditions cause severe head pain. Both are far more painful than a tension headache. Both can involve one-sided head pain. Both are "invisible" conditions with no visible external signs in most cases, and neither has a definitive diagnostic test - diagnosis is based on the pattern of symptoms, not a blood test or a head scan. And migraine is much more common and better known, so when someone presents with severe head pain, migraine is often the first diagnosis considered.
But the similarities largely end there. The clinical picture of cluster headache is actually quite distinct from migraine if you know what to look for.
Side-by-side comparison
| Cluster headache | Migraine | |
|---|---|---|
| Attack duration | 15 minutes to 3 hours | 4–72 hours |
| Pain severity | Usually 9–10/10, extreme | Moderate to severe, often 6–9/10 |
| Pain location | Always one-sided, always around the eye or temple | Often one-sided but can be both sides; varies location |
| Eye/nasal symptoms | Very common: red eye, tearing, droopy lid, nasal congestion on pain side | Watery eyes and runny nose can occur, but more often on both sides |
| Behaviour | Agitated, pacing, rocking - cannot stay still | Prefers to lie still in dark, quiet room |
| Nausea/vomiting | Sometimes, usually mild | Very common, often severe |
| Light/sound sensitivity | May occur, usually mild | Very common and pronounced |
| Aura | Rare | Common in about 30% of patients |
| Gender | More common in men (3:1) | More common in women (3:1) |
| Frequency | From one every other day up to 8 per day during a cluster period | Typically 1–8 attacks per month (around 8–10% have chronic migraine, with 15 or more headache days a month) |
| Cluster pattern | Attacks in periods lasting weeks to months; remissions between | Does not follow a cluster pattern |
| Response to triptans | Injection only - tablets are too slow | Tablets work for most people; injection is available if needed |
| Response to oxygen | Very effective (70–80% of patients) | Not a standard treatment for migraine |
The most telling differences in practice
Duration
A migraine typically lasts at least 4 hours and, untreated, can last up to 3 days. A cluster headache attack rarely lasts more than 3 hours. If someone describes severe attacks that come and go within an hour, that is much more suggestive of cluster headache than migraine.
Behaviour during the attack
This is the most clinically distinctive difference. A patient lying in a dark room is probably describing a migraine. A patient who cannot sit still, who paces, rocks or bangs their head against a wall, is almost certainly describing cluster headache.
Eye and nasal symptoms
The ipsilateral (same side as the pain) eye and nasal features - red eye, tearing, drooping eyelid, nasal blockage - are classic features of cluster headache and are not typical of migraine. Watery eyes and a runny nose can occur in migraine too, but more often on both sides; a red, swollen or drooping eye, a small pupil, and flushing or sweating on one side of the face are not typical migraine features. A patient describing one red, streaming eye during their attacks should prompt consideration of cluster headache.
Response to treatment
Migraine-specific treatments (particularly preventive treatments like amitriptyline, topiramate used for migraine, and CGRP antibodies for migraine) do not reliably work for cluster headache. If someone has been treated for migraine for years and the treatment is not working, it is worth reconsidering the diagnosis.
Can a person have both?
Yes. Migraine and cluster headache are different conditions but they are not mutually exclusive. Some people have both. If you have cluster headache, you can also have separate migraine attacks. The two conditions need to be managed separately.
If your current diagnosis is migraine but you recognise the cluster headache description more clearly, speak to your GP and ask for a review. It can help to keep a headache diary for a few weeks documenting your attacks in detail - duration, which side, associated symptoms, your behaviour during the attack. See our page on getting a diagnosis in New Zealand for practical next steps.
And if it turns out migraine is the right diagnosis, you are in good hands with the Migraine Foundation Aotearoa New Zealand. They are New Zealand's charity for people living with migraine, and their information and advocacy work is excellent.