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neuro.cluster-headache.core.v1

Cluster Headache

neurologysubacuteadultoutpatientacute
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Phase B deepening (2026-05-14): TAC phenotypes (episodic CH, chronic CH, status clusteribus, SUNCT/SUNA, paroxysmal hemicrania, triptan-CI pivot, verapamil PR-prolongation, first-attack-imaging) encoded as 8 severity_triggers — each carries phenotype-specific management branch + evidence anchor. 5 setting playbooks span the full cluster journey: home (patient action plan — O2 setup + sumatriptan SC autoinjector + bout-onset signal) → ed (STAT O2 + sumatriptan + first-attack MRI; octreotide if triptan-CI) → icu (rare — medication-induced cardiac complication: triptan/ergot coronary vasospasm or verapamil heart block) → inpatient (transitional ladder — Raskin IV DHE protocol for status clusteribus with telemetry; GON block; SPG block consideration) → outpatient (primary site — verapamil titration to 480–960 mg/d with ECG-gated PR <200 ms, transitional prednisone, galcanezumab episodic only per CGAL, lithium chronic, SPG stimulator referral for refractory chronic). Trial-quality PMIDs (all NEEDS_SOURCE_REVIEW per shard convention): ICHD-3 (29368949), AAN 2010 Robbins (27432623), Cohen JAMA 2009 high-flow O2 (19996400), CGAL Goadsby NEJM 2019 (31291515), FOCUS Ferrari Lancet Neurol 2019 negative fremanezumab chronic (32241175), Pathway CH-1 Schoenen Cephalalgia 2013 SPG-stim (23314784), Raskin Neurology 1986 DHE protocol (3520384). Replaces prior POINT (29766750 — TIA antiplatelet, wrong engine) + REDUCE (23900119 — PFO, wrong engine). Sibling differentiation: neuro.migraine.core.v1 (duration/autonomic/behaviour/M:F + entirely different preventive ladder; CGRP mAbs work in migraine across phenotypes, in cluster only episodic per CGAL/FOCUS) + rheum.gca.chronic.v1 (age >50 + ESR/CRP + temporal artery biopsy pivot — do not miss GCA in any new headache >50). Schema-blocked items (forbidden by shard file scope; surfaced as tickets in docs/framework-audit/shard-3-neuro-sym-state.md): no cluster-headache-specific calculator in clinical-tools-registry.ts (no ICHD-3 attack scorer; no verapamil-titration protocol; no SUNCT-vs-cluster scorer; no Ottawa-style ED rule-out for new-onset cluster mimics). Calculators array left empty intentionally; surfaced in depth bundle §4. Pivot — triptan contraindication: high-flow O2 + octreotide 100 mcg SC + gammaCore nVNS are the non-vasoconstrictor abortive triad. Pivot — paroxysmal hemicrania / hemicrania continua: indomethacin-responsive — DO NOT commit to cluster ladder until indomethacin trial. Pivot — SUNCT/SUNA: lamotrigine first-line, not verapamil. Pivot — status clusteribus: inpatient Raskin DHE protocol with continuous telemetry, not outpatient escalation.

Entry points (4)

  • symptom
    Severe unilateral orbital/periorbital pain (15–180 min) (ICHD-3 PMID 29368949)
    unilateral_orbital_pain
  • symptom
    Ipsilateral lacrimation / conjunctival injection / rhinorrhea / ptosis / miosis (ICHD-3 PMID 29368949)
    cranial_autonomic_features
  • symptom
    Stereotyped attacks 1–8/day during a bout (ICHD-3 PMID 29368949)
    cluster_attack_pattern
  • problem_list
    Existing CH on problem list (preventive titration) (AAN 2010 Robbins PMID 27432623)
    cluster_headache

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Age + sex shape DDx (CH male predominance, GCA in >50, trigeminal neuralgia bimodal) (ICHD-3 PMID 29368949)
  • attack_durationrequired
    symptom • used at DIFFERENTIAL
    ICHD-3 requires 15–180 min untreated attacks to meet CH criteria; <30 min → paroxysmal hemicrania mimic; very short (<10 min, very frequent) → SUNCT/SUNA (PMID 29368949)
  • attack_frequency_per_dayrequired
    symptom • used at CONTEXT
    Bout activity vs remission drives preventive vs bridge therapy; >5/day with very brief attacks → SUNCT (PMID 29368949)
  • autonomic_featuresrequired
    symptom • used at DIFFERENTIAL
    Ipsilateral autonomic features distinguish CH/TACs from migraine; presence + side-locked unilaterality is binding criterion (PMID 29368949)
  • episodic_vs_chronicrequired
    history • used at DIFFERENTIAL
    Episodic CH (bouts of weeks-months separated by remissions ≥3 mo) vs chronic CH (no remission ≥3 mo or <3 mo within 1 yr) branches galcanezumab eligibility (CGAL — galcanezumab approved for episodic only) (Goadsby NEJM 2019 PMID 31291515)
  • bout_duration_so_far
    history • used at RISK_STRATIFICATION
    Status clusteribus = cluster bout ≥1 mo without remission requiring aggressive inpatient bridge (DHE per Raskin 1986 PMID 3520384)
  • mri_brain_pituitary
    imaging • used at INITIAL_WORKUP
    Exclude secondary causes at first presentation — pituitary adenoma can mimic CH; cavernous sinus lesions, AVM, dissection (AAN 2010 Robbins PMID 27432623)
  • hr
    vital • used at TREATMENT
    Verapamil titration requires baseline HR + serial ECG (PR interval) (AAN 2010 PMID 27432623)
  • sbp
    vital • used at TREATMENT
    Verapamil + steroid bridge can lower BP; uncontrolled HTN/CAD/PVD = triptan contraindication (AAN 2010 PMID 27432623)
  • creatinine
    lab • used at TREATMENT
    Lithium dosing + verapamil renal monitoring (AAN 2010 PMID 27432623)
  • tsh
    lab • used at TREATMENT
    Lithium thyroid monitoring baseline (AAN 2010 PMID 27432623)
  • lithium_level
    lab • used at MONITORING
    Therapeutic monitoring on lithium prevention; target 0.6–1.2 mEq/L for chronic CH (AAN 2010 PMID 27432623)
  • cad_or_uncontrolled_htnrequired
    history • used at TREATMENT
    Triptan absolute contraindication — pivot to octreotide 100 mcg SC or high-flow O2 only (AAN 2010 PMID 27432623)
  • current_meds
    medication • used at CONTEXT
    Detect triptan overuse, MAOIs (24h washout), CYP3A4 interactions for verapamil (AAN 2010 PMID 27432623)

12-phase flow (10)

  1. 1FRAME
    Confirm primary trigeminal autonomic cephalalgia scope; exclude SAH/dissection/pituitary apoplexy mimics (AAN 2010 PMID 27432623)
    inputs: attack_duration, autonomic_features
    advance: thunderclap and structural mimics ruled out
  2. 2ENTRY
    Recognise unilateral orbital pain + autonomic features as TAC (ICHD-3 PMID 29368949)
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Capture vitals, comorbidities, current meds, episodic vs chronic pattern, bout duration (AAN 2010 PMID 27432623)
    inputs: hr, sbp, current_meds, attack_frequency_per_day, cad_or_uncontrolled_htn
    advance: context captured
  4. 4RED_FLAGS
    Screen for SAH, dissection, GCA, pituitary apoplexy, raised ICP (AAN 2010 PMID 27432623)
    actions: acute_headache
    advance: no red flags or routed
  5. 5INITIAL_WORKUP
    MRI brain with pituitary + cavernous sinus views at first presentation; baseline labs for preventive plan (AAN 2010 PMID 27432623)
    inputs: mri_brain_pituitary, creatinine, tsh
    advance: imaging + baseline labs back
  6. 6DIFFERENTIAL
    Apply ICHD-3 criteria; episodic vs chronic vs probable CH; rule out paroxysmal hemicrania (indomethacin-responsive pivot), hemicrania continua (indomethacin pivot), SUNCT/SUNA (lamotrigine first-line), trigeminal neuralgia (carbamazepine), GCA (>50, ESR/CRP, biopsy) (ICHD-3 PMID 29368949)
    inputs: attack_duration, autonomic_features, episodic_vs_chronic
    advance: ICHD-3 criteria met and phenotype assigned
  7. 7RISK_STRATIFICATION
    Bout duration ≥1 mo without remission = status clusteribus → inpatient DHE bridge (Raskin 1986 PMID 3520384)
    inputs: bout_duration_so_far
    advance: severity tier assigned
  8. 8TREATMENT
    Acute (high-flow O2 12–15 L/min via NRB × 15–20 min per Cohen JAMA 2009 PMID 19996400 + SC sumatriptan 6 mg + zolmitriptan IN 5–10 mg) + bridge prednisone 60–100 mg + GON block + preventive verapamil 80 → 480–960 mg/d (PREVA) ± galcanezumab 300 mg SC monthly (episodic only — Goadsby NEJM 2019 PMID 31291515); octreotide if triptan-contraindicated (AAN 2010 PMID 27432623)
    inputs: hr, sbp, episodic_vs_chronic, cad_or_uncontrolled_htn
    advance: acute + preventive regimen prescribed with monitoring plan
  9. 9MONITORING
    Attack diary, ECG before each verapamil up-titration (PR <200 ms ceiling), lithium level + Cr + TSH q3 mo on lithium (AAN 2010 PMID 27432623)
    inputs: lithium_level, creatinine, tsh
    advance: monitoring plan documented
  10. 10FOLLOWUP
    Headache neurology referral if refractory; bout-end taper plan; SPG / occipital nerve stimulator candidacy for refractory chronic CH (Schoenen Cephalalgia 2013 SPG-stim Pathway CH-1 PMID 23314784)
    advance: follow-up cadence + return precautions set