Migraine vs Cluster Headache: How to Tell Them Apart
Migraine and cluster headache are both primary headache disorders that can produce severe, disabling pain and are diagnoses of exclusion once dangerous secondary causes are ruled out. The core axis that separates them is the pattern: migraine is a pulsating headache with nausea and photophobia where the patient wants to lie still, while cluster headache is an excruciating unilateral orbital pain with prominent ipsilateral autonomic features and marked restlessness.
How to tell them apart
| Feature | Migraine | Cluster headache |
|---|---|---|
| Laterality | Unilateral in about 60% of attacks, but can be bilateral; not fixed to one side | Strictly unilateral, typically side-locked within a given cluster period; the side can shift between bouts in a minority of patients (~15–20%) |
| Pain quality and intensity | Pulsating/throbbing, moderate to severe | Excruciating, severe orbital/periorbital or temporal pain |
| Duration | Prolonged: headache phase lasts 4–72 hours | Short: attacks last 15–180 minutes |
| Autonomic features | Not a defining feature; dominated by nausea, vomiting, photophobia, phonophobia | Prominent ipsilateral autonomic signs: conjunctival injection, lacrimation, nasal congestion/rhinorrhea, ptosis, miosis, eyelid edema, facial sweating |
| Patient behavior | Patient lies still; pain is worsened by routine physical activity | Patient is restless—paces, rocks, or bangs the head |
| Aura and prodrome | Can have a prodrome (hours–days) and aura (visual, sensory, rarely motor) in ~25% of patients | No aura; attacks recur in clusters, often striking at the same time each day |
| Acute treatment | Triptans, which constrict cranial vessels and inhibit CGRP release | High-flow 100% oxygen or subcutaneous sumatriptan |
| Preventive treatment | First-line prophylaxis is beta-blockers (propranolol), anticonvulsants (topiramate, valproate), or TCAs (amitriptyline); CGRP monoclonal antibodies (e.g., erenumab) are reserved for frequent or refractory migraine | Verapamil is first-line for prevention |
The reasoning
Anchor on the triad of laterality, duration, and patient behavior. A patient who lies still with a throbbing headache lasting many hours, accompanied by nausea and both photophobia and phonophobia, is describing migraine. A patient who is pacing, banging the head, in excruciating strictly one-sided orbital pain lasting under a few hours—with ipsilateral tearing, a running nostril, and a drooping lid, especially recurring at the same time each night in a cluster over weeks—is describing cluster headache. The presence of ipsilateral cranial autonomic features plus restlessness is the decisive arbitrator toward cluster. Remember that both are diagnoses of exclusion: if the headache is sudden and maximal (thunderclap), the worst ever, or accompanied by focal neurological signs, abandon the primary-headache label and image to rule out subarachnoid hemorrhage or other secondary causes.
Key tests
- Clinical history and headache diary: distinguishes migraine's 4–72 hour pulsating attacks with nausea/photophobia from cluster's 15–180 minute unilateral attacks recurring at the same time daily in clusters over weeks
- Neurological examination: normal in both; any focal deficit or abnormal exam mandates neuroimaging to exclude a structural cause
- Response to high-flow oxygen: aborts cluster attacks and supports that diagnosis, whereas it is not a migraine therapy
What they share
- Both are primary headache disorders—the headache itself is the disease, diagnosed after excluding secondary causes
- Both can cause severe pain and are associated with photophobia
- Both can present unilaterally
- Both have a normal neurological examination between and during attacks (no focal deficits)
Pitfalls
- Assuming unilateral pain automatically means cluster—migraine is unilateral in roughly 60% of attacks; use the autonomic features, duration, and behavior to differentiate
- Assuming cluster headache never switches sides—although attacks are side-locked within a bout, the affected side can shift between different cluster periods in a minority of patients
- Overlooking the behavioral clue: migraineurs lie still while cluster patients are restless and pace—a simple observation that strongly separates them
- Defaulting to CGRP monoclonal antibodies as the first-line migraine preventive—the classic initial agents remain beta-blockers, topiramate/valproate, and amitriptyline, with CGRP agents reserved for frequent or refractory disease
- When a known migraineur says 'this headache is different,' believe them; even migraineurs can have subarachnoid hemorrhage, meningitis, or another emergency
- Forgetting that both are primary headaches diagnosed only after excluding dangerous secondary causes—any red flag or abnormal neurological finding demands imaging
- Confusing photophobia as migraine-specific; cluster headache patients can also be light-sensitive, so it does not by itself distinguish the two
Practice this the way the exam tests it — on branching cases where your decisions shape the patient.