Clinical reference · Card 03 of 11 · Pathway
Primary care pathway — suspected cluster headache
Severe, strictly unilateral orbital / supraorbital / temporal attacks
1Screen — ETCH, three questions (Card 01)
2Confirm — ICHD-3 3.1 criteria A–E (Card 02)
Any SNNOOP10 red flag, abnormal neurology or atypical features?
YES → Urgent referral or imaging per red flag (Card 04)
NO
First bout? NICE: discuss the need for neuroimaging with a GP with a special interest in headache or a neurologist. EAN: cranial MRI including the craniocervical junction at initial diagnosis, to exclude a secondary cause.
Start acute treatment now — do not wait for imaging or referral100% oxygen ≥12 L/min via non-rebreather mask with reservoir bag, and/or subcutaneous or nasal triptan.
Bout ongoing → consider verapamil prophylaxis. If unfamiliar, seek specialist advice first, including on ECG monitoring (Card 10).
No response to verapamil, pregnancy, or chronic form → seek specialist advice / refer.
DO NOToffer paracetamol, NSAIDs, opioids, ergots or oral triptans for acute cluster attacks (NICE 1.3.38).
DO NOTrefer for neuroimaging solely for reassurance once the diagnosis is made (NICE 1.3.3).
SOURCES NICE CG150 (updated June 2025) §1.1.1, 1.2.1, 1.3.34–1.3.41. May A et al. EAN guideline, Eur J Neurol 2023;30(10):2955–2979.
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