Cluster Headache Diagnosis and Exclusion Criteria

Diagnostic Features

The International Headache Society diagnostic criteria for cluster headache require severe unilateral pain in the orbital/periorbital region lasting 15-180 minutes, frequency of 1-8 attacks daily, ipsilateral autonomic symptoms, restlessness or agitation during attacks, and a clustering pattern with attacks occurring in bouts during specific times of year 1

Migraine without aura is ruled out because its attacks last 4-72 hours, not 90 minutes, and patients prefer to lie still in a dark, quiet room, whereas cluster headache patients often pace and find lying down unhelpful 1, 2, 3
Giant cell arteritis is excluded because it affects patients over age 50, presents with continuous dull aching pain, jaw claudication, and systemic symptoms like fever and malaise, and is incompatible with the short-duration paroxysmal attacks of cluster headache 5
Carotid artery dissection is ruled out because it causes continuous pain, not episodic 90-minute attacks, and would present with focal neurological deficits and require urgent vascular imaging 6
Medication-overuse headache is excluded because it requires ≥15 headache days per month with regular overuse of acute medications for >3 months, and the episodic clustering pattern with remission periods is incompatible with medication-overuse headache 4

The American Academy of Otolaryngology-Head and Neck Surgery recommends considering cluster headache in patients with severe unilateral periorbital pain, ipsilateral autonomic symptoms, and a clustering pattern 2, 3
The International Headache Society guidelines state that cluster headache is characterized by short-duration attacks, restlessness during pain, and strict unilateral autonomic symptoms, which distinguish it from other headache disorders 1