Clinical reference · Card 06 of 11 · Differential
Cluster vs migraine — the discriminating features
CLUSTERMIGRAINE
Duration15–180 min4–72 hours
Behaviour in attackRestless, agitated, pacesLies still; movement worsens it
LateralityStrictly unilateral, side-locked ~78%Often unilateral; may switch sides or be bilateral
Circadian timingAttacks at the same hour; nocturnal onset commonNo consistent circadian pattern
Autonomic featuresNear-obligatory (absent in ~3%)Present in a minority
Frequency1 every other day to 8 per dayTypically <15 days/month if episodic
Sex ratioMale-predominant, but falling: 6.2:1 (pre-1960) → 2.1:1 (1990s). Recent cohorts 1.9–4.9:1 (Card 07)Female-predominant, ~3:1
Lifetime prevalence~1 in 1,000 (124 per 100,000)~14% of adults
High-flow oxygen78% pain-free at 15 min vs 20% on air (RCT)Not an established treatment
Overlap warningPhotophobia, phonophobia and nausea occur in cluster headache too, and are among the features most associated with diagnostic delay (van Vliet, JNNP 2003). Do not let them override duration and restlessness. The sex ratio is a weak prior only — falling, 1.9–4.9:1 across contemporary cohorts, inverted after age 50, and measured in referred clinic populations. Never use it to argue against the diagnosis.
SOURCES ICHD-3 2018; Bahra A, May A, Goadsby PJ. Neurology 2002;58(3):354–361; Cohen AS et al. JAMA 2009;302(22):2451–2457; Fischera M et al. Cephalalgia 2008;28(6):614–618; EAN guideline 2023.
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