How do cluster headaches typically present?

• A. Bilateral frontal headache with fever
• B. Headache with nausea and photophobia
• C. Rhinorrhea, unilateral orbital pain, restless, facial flushing, worse with lying down
• D. Chronic daily headache with dull pressure

Answer: (C)

Cluster headaches are a trigeminal autonomic cephalalgia. They present with sudden, extremely severe unilateral orbital or periorbital pain on one side, accompanied by ipsilateral autonomic symptoms such as rhinorrhea, tearing, nasal congestion, conjunctival injection, facial flushing, or sweating. A hallmark is the patient’s restlessness during the attack, often pacing or moving rather than lying still, and attacks frequently occur at night or early morning, sometimes waking the patient. The pattern of short, intense attacks that cluster over weeks to months fits this description well.

The described features—rhinorrhea, unilateral orbital pain, restlessness, facial flushing, and worse with lying down—capture the unilateral orbital pain with ipsilateral autonomic signs and nocturnal/aggravating tendency characteristic of cluster headaches.

Other patterns don’t fit as well: a bilateral frontal headache with fever suggests infection or sinusitis; migraine can include nausea or photophobia but typically lacks prominent unilateral autonomic signs and marked restlessness; chronic daily dull headaches resemble tension-type headaches more.