Migraine vs Cluster Headache

How to Tell the Difference

Frequent or severe headaches can be frightening, frustrating, and completely disruptive to daily life. Many people in South Africa live for years with “bad headaches” without ever receiving a clear diagnosis – or they are told they have “sinus” or “stress” headaches when the real problem is neurological.

Two of the most disabling primary headache disorders are migraines and cluster headaches. They can both be extremely painful, but they are not the same condition. Understanding the difference between migraine vs cluster headache can help you get the correct diagnosis, access effective treatment, and stop blaming yourself for “not coping”.

This guide explains how these two conditions differ in terms of causes, symptoms, triggers, duration, and treatment – with a specific focus on what this means for patients seeking care in South Africa.

 

Understanding Headaches: An Overview

Not all headaches are created equal. In medicine, we broadly divide headaches into two groups:

Primary headaches
These are headache disorders where the headache itself is the main problem – there is no underlying tumour, bleed, infection, or structural abnormality causing it. Migraine and cluster headache both fall into this group, along with tension-type headaches and some other less common conditions.

Secondary headaches
These are headaches caused by another underlying problem, such as meningitis, brain haemorrhage, stroke, head injury, uncontrolled high blood pressure, or certain medications. These headaches are red flags that something else may be seriously wrong and often need urgent investigation.

This article focuses on primary headache disorders – specifically migraine and cluster headaches. However, any new, sudden, severe, or changing headache pattern must be evaluated by a doctor to rule out dangerous secondary causes.

 

What Is a Migraine?

A migraine is a neurological disorder characterised by recurrent, often disabling headache attacks. It is much more than “just a bad headache”. A migraine attack typically involves:

Common migraine symptoms

• Moderate to severe throbbing or pulsating pain
• Pain often on one side of the head, but it can be both
• Pain made worse by movement, bending, or climbing stairs
• Nausea and/or vomiting
• Sensitivity to light (photophobia)
• Sensitivity to sound (phonophobia)
• Difficulty concentrating, fatigue, irritability

Some people also experience aura – temporary neurological symptoms that can include flashing lights, zig-zag lines, blind spots, tingling, or difficulty speaking. Aura usually develops gradually and lasts 5–60 minutes.

Typical duration
A migraine attack usually lasts between 4 and 72 hours if untreated. For some people, the “migraine hangover” can last another day or two, leaving them exhausted and foggy.

Impact on life
Migraines can significantly affect quality of life, making it hard to work, study, parent, drive, or socialise. Many people with chronic migraine (15 or more headache days per month) feel misunderstood, especially if their brain scans are “normal”.

 

Common migraine triggers

Triggers differ for each person, but may include:

• Stress or stress let-down
• Hormonal changes (especially in women around menstruation or menopause)
• Lack of sleep or oversleeping
• Certain foods (e.g. processed meats, aged cheese, red wine)
• Dehydration
• Bright lights, strong smells, or loud noise
• Changes in weather or barometric pressure

Migraines often run in families, suggesting a strong genetic component.

 

What Is a Cluster Headache?

 

Cluster headache is a rare but extremely severe primary headache disorder. It is sometimes called the “suicide headache” because the pain can be so intense that sufferers feel desperate during an attack.

Key features of cluster headache

• Sudden onset of excruciating, burning or piercing pain
• Pain always on one side, usually around or behind one eye or temple
• Restlessness or agitation – patients often cannot sit still and may pace or rock
• Attacks usually last 15 minutes to 3 hours

Typical associated symptoms on the affected side of the face

• Tearing or watering of the eye
• Redness of the eye
• Drooping eyelid
• Nasal congestion or runny nose
• Sweating on the forehead or face
• A sense of fullness around the eye

Unlike people with migraines, who often want to lie quietly in a dark room, people having a cluster headache attack are usually restless and distressed.

Cluster pattern (“bouts” or “cycles”)

Cluster headaches tend to occur in clusters or bouts – for example:

• Daily or multiple attacks per day, often at the same time (even at night)
• Bouts lasting weeks to months
• Followed by remission periods (months to years with no attacks)

Cluster headache is less common than migraine but often more severe. It is more frequent in men than women and typically starts between ages 20 and 50.

 

Key Differences Between Migraine and Cluster Headache

 

Because both conditions can cause intense, one-sided head pain, confusion is common. So how do you know if you have a migraine or a cluster headache?

Here is a side-by-side comparison:

Feature	Migraine	Cluster Headache
Location of pain	Often one-sided, can switch sides or be bilateral	Strictly one-sided, usually around/behind one eye
Pain quality	Throbbing, pulsating, moderate to severe	Piercing, burning, drilling, excruciating
Duration of single attack	4–72 hours	15–180 minutes (most 30–90 minutes)
Frequency	Variable: occasional to chronic; not strictly timed	Up to 8 attacks per day in clusters, often same time
Behaviour during attack	Prefers to lie still in dark, quiet room	Restless, agitated, pacing or rocking
Associated symptoms	Nausea, vomiting, light and sound sensitivity, sometimes aura	Tearing, red eye, blocked/runny nose, drooping eyelid, facial sweating
Triggers	Stress, hormones, sleep changes, foods, sensory stimuli	Alcohol (during a bout), strong smells, sometimes sleep pattern changes
Demographics	More common in women; often family history	More common in men; less common overall

Some people can have both migraine and cluster headache, just to keep things spicy. That’s why a careful clinical history from a headache-savvy doctor is crucial.

 

Diagnosis and When to Seek Medical Help

Diagnosis of migraine vs cluster headache in South Africa is mostly clinical – based on your symptoms, pattern of attacks, and examination. There is no single blood test or scan that “proves” either condition.

Typical diagnostic steps

• Detailed medical history: age of onset, frequency, timing, duration, associated symptoms, triggers, response to medication
• Physical and neurological examination
• Headache diary: tracking when headaches occur, how long they last, what they feel like, and what helps
• Exclusion of secondary causes: brain imaging (CT or MRI) may be done if red flags are present

Red-flag symptoms – seek urgent care immediately if you have:

• Sudden, severe “thunderclap” headache (worst headache of your life)
• Headache with fever, neck stiffness, confusion, or seizures
• Headache after head injury
• New headache in someone over 50
• Headache with weakness, vision loss, speech difficulty, or balance problems

These could indicate a serious secondary cause such as haemorrhage, infection, stroke, or tumour and must be investigated urgently.

If your headaches are frequent, disabling, or not responding to over-the-counter medication, it is time to see a GP, neurologist, or multidisciplinary pain specialist. In South Africa, specialised headache management is increasingly available in structured pain clinics.

 

Treatment Options in South Africa

 

Both migraine and cluster headaches are treatable. The key is matching the right treatment to the right diagnosis.

Migraine treatment options

1. Acute (abortive) treatments – taken during an attack
• Simple painkillers (paracetamol, NSAIDs)
• Triptans (e.g. sumatriptan), specifically designed for migraine
• Antiemetics for nausea and vomiting
• Rest in a dark, quiet room
2. Preventive (prophylactic) treatments – taken daily to reduce frequency and severity
• Beta-blockers, certain antidepressants, or anticonvulsants
• CGRP-targeted treatments (where available)
• Botox injections for chronic migraine in some specialised centres
• Lifestyle modification: sleep hygiene, hydration, trigger management

Cluster headache treatment options

Because cluster attacks are extremely rapid and intense, treatments must act fast.

1. Acute treatments
• High-flow oxygen via a face mask (often dramatically effective if used early)
• Fast-acting triptans (subcutaneous or nasal forms)
2. Preventive treatments
• Verapamil (a calcium channel blocker) is the most commonly used preventive
• Corticosteroids may be used short term at the start of a cluster bout
• Other medications may be used in specialist settings for resistant cases

In South Africa, access to some of these treatments can vary depending on medical aid schemes, public vs private sector, and specialist referral. A multidisciplinary pain or headache clinic can help coordinate medical management, interventional options, and psychological support.

Interventional and neuromodulation options
For patients with severe, refractory headache disorders, advanced treatments may be considered, such as:

• Occipital nerve blocks
• Pulsed radiofrequency of occipital nerves
• Neuromodulation techniques in specialised settings

These are usually reserved for people who have tried multiple standard therapies without adequate relief.

 

Living with Chronic Headaches

 

Whether you have migraine or cluster headaches, day-to-day life can feel like navigating a minefield. While medication is vital, lifestyle and self-management strategies also matter.

Practical steps include:

• Keep a headache diary: note time, duration, triggers, medication, and relief
• Maintain regular sleep and meal patterns
• Stay hydrated
• Limit alcohol, especially if you have cluster headache (alcohol can reliably trigger an attack during a cluster bout)
• Manage stress using tools such as mindfulness, breathing exercises, or CBT-based techniques
• Exercise regularly within your capacity – movement can help modulate the nervous system over time
• Avoid medication overuse: taking painkillers too often can cause rebound headaches

In a South African context, where access and resources vary, having a clear diagnosis and a realistic, personalised plan is crucial. Some multidisciplinary pain clinics offer integrated programmes combining medical treatment, physiotherapy, occupational therapy, psychology, and education for people living with chronic headache disorders.

 

Final Thoughts

 

If you are struggling with frequent or severe headaches, you do not have to figure out migraine vs cluster headache on your own – and you definitely do not have to “just live with it”.

Both conditions are real, neurological disorders with well-described patterns and evidence-based treatments. The right diagnosis opens the door to targeted therapy, fewer attacks, and a better quality of life.

If your headaches are disabling, unpredictable, or worrying you, speak to your GP or book an assessment with a neurologist or pain clinic in South Africa. An accurate diagnosis, combined with modern treatment and self-management strategies, can change the trajectory of your life with pain.

Relief is not a luxury. With the right help, it is a realistic goal.

 

FAQs

How can I tell if my headache is a migraine or a cluster headache?

Migraines usually cause throbbing pain on one side of the head, sensitivity to light and sound, and nausea. They build gradually and last hours to days.
Cluster headaches cause explosive, one-sided pain around the eye or temple, usually with tearing, nasal congestion, and agitation. They occur in short, repeated attacks (15–180 minutes) over weeks.

If your pain comes in cycles of identical, severe attacks at the same time of day or night, it’s far more likely to be cluster headache.
A pain diary and clinical exam are the best ways to differentiate them reliably.

Are cluster headaches more painful than migraines?

Yes. Cluster headaches are widely considered one of the most painful conditions in medicine — often called “suicide headaches” due to their intensity.
Migraines can be severely disabling, but cluster headaches are typically sharper, more explosive, and drive sufferers to pace, rock, or become restless during an attack.
Both conditions require medical treatment, but cluster headaches almost always demand urgent, specific intervention.

What causes cluster headaches to occur in cycles?

Cluster headaches are believed to originate from the hypothalamus, the deep-brain region that controls sleep, hormones, and circadian rhythms.
This built-in biological clock explains why attacks often occur:

• At the same time every day
• During specific seasons
• In “clusters” lasting weeks to months
  Triggers such as alcohol, strong smells, temperature changes, and disrupted sleep can aggravate attacks during active cluster periods.

Can migraines turn into cluster headaches over time?

No. Migraines and cluster headaches are distinct neurological disorders with different mechanisms.
A person can have both conditions, but one does not transform into the other.
However, severe migraines can sometimes mimic cluster-like symptoms, creating diagnostic confusion — which is why a specialist evaluation is important.

What are the best treatments for chronic migraines in South Africa?

Effective treatment depends on the pattern and severity of symptoms. Evidence-based options available in South Africa include:

• Preventive medications: topiramate, amitriptyline, beta-blockers, candesartan
• Triptans (for acute attacks): sumatriptan, rizatriptan, zolmitriptan
• Botox injections every 12 weeks (for chronic migraine)
• Neuromodulation treatments: pulsed radiofrequency for occipital neuralgia and trigeminal pathways
• Lifestyle and trigger management: sleep routines, hydration, caffeine moderation, and stress management
• Multidisciplinary care: physiotherapy, occupational therapy, and pain psychology available at specialised pain clinics