Trigeminal autonomic cephalalgias — specialist care in Sydney
Neurologist-led diagnosis and treatment for paroxysmal hemicrania, hemicrania continua, SUNCT/SUNA and cluster headache at CURA Medical Specialists, Drummoyne and Penrith.
The trigeminal autonomic cephalalgias are a small family of severe one-sided headaches — cluster headache, paroxysmal hemicrania, hemicrania continua and SUNCT/SUNA — unmistakable once recognised but easily missed.
Reviewed for general neurology accuracy by Dr Usman Ashraf; the headache and TAC clinic is led by Dr Usman Ashraf, and your appointment will be with Dr Ashraf or another member of our neurology team.
Tap or hover any dotted-underlined term for a plain-English definition.
Most trigeminal autonomic cephalalgias are treatable, often very effectively, once the diagnosis is right. Cluster headache responds reliably to oxygen and the right preventive; paroxysmal hemicrania and hemicrania continua are defined by their response to indomethacin. The barrier is usually diagnostic delay — not a lack of options. The emergency notice below is for people experiencing a sudden severe headache right now.
A GP referral is required for the Medicare rebate. Specialist consultation fees apply — please call our reception on (02) 7906 8356 for current fees and the next available appointment at Drummoyne or Penrith.
Severe one-sided pain around or behind one eye, the temple or above the eyebrow
On the painful side: a red, watery eye, a blocked or running nostril, a drooping or swollen eyelid, sweating or flushing
You feel restless or agitated during attacks — pacing, rocking, banging the head — rather than wanting to lie still
Attacks come in clockwork patterns — same time of year, same time of night (often around 1–3 am waking you from sleep)
Alcohol triggers an attack within minutes when you are in a bout (and is harmless between bouts)
If three or more of these sound like you, this is very likely a trigeminal autonomic cephalalgia and we can help. Read on, or jump straight to what to do this week.
At a glance
Trigeminal autonomic cephalalgias are a small family of primary headaches that share two features: severe one-sided pain in the trigeminal distribution, and autonomic features on the same side as the pain. The four named TACs are cluster headache, paroxysmal hemicrania, hemicrania continua and SUNCT / SUNA.
Cluster headache is the most common TAC but is still uncommon — affecting roughly 1 in 1,000 people in their lifetime, with a male predominance and a peak age of onset in the 20s to 40s. It is one of the most painful conditions in medicine and is reliably treatable with the right plan.
Paroxysmal hemicrania and hemicrania continua are defined by their response to indomethacin — a particular non-steroidal anti-inflammatory drug. At the right dose, it abolishes the headache. We use a structured indomethacin trial as both the diagnostic test and the start of treatment, with a stomach-protecting medication.
Diagnostic delay is the main barrier to good outcomes. The average person with cluster headache waits years for the diagnosis — often misdiagnosed as migraine, sinus headache, or dental pain. A neurologist visit and an early MRI brain are what change the trajectory.
Directory
You think it’s a TAC — what now?
This week
Start a strict attack diary. Note: date and exact time of each attack, how long it lasted, severity (0–10), which side, what autonomic features you noticed (red eye, watery eye, blocked nostril, droopy eyelid), what you were doing or drinking, and whether you paced or could lie still. A simple notebook or a free app like Migraine Buddy (which works for cluster too) is fine.
Take a phone video if a family member can — an attack on video, showing the autonomic features, can short-cut the diagnostic process by months.
See your GP for a referral. Ask specifically for a referral to a neurologist with a headache interest, and mention cluster headache or TAC by name. This is what enables Medicare rebates and the right pathway from day one.
Before your appointment
Bring your attack diary, your GP referral, any phone videos, a list of every medication you have tried (with dose, duration, and reason for stopping), your current medications, and any previous brain imaging.
Write down your three most disruptive symptoms and the question you most want answered. The first appointment is yours.
If symptoms escalate
A sudden “worst-ever” headache, headache with fever and neck stiffness, headache with new weakness, slurred speech or vision loss, or headache after a head injury — call 000 or go to the nearest ED.
A new headache pattern in pregnancy or the postpartum period needs same-day assessment with your GP or maternity team.
Most TACs are not life-threatening, but they are excruciating and treatable — the sooner you are seen, the sooner the right treatment can start.
I.
What TACs are
The trigeminal autonomic cephalalgias are a small family of primary headaches — severe and unmistakable when seen, but easily missed if you are not looking for them.
They share two features that hold the family together. First, the pain is strictly one-sided in the territory of the trigeminal nerve — behind or around the eye, in the temple, or above the eyebrow. Second, the painful side shows autonomic features driven by a brainstem reflex linking trigeminal pain to autonomic output: red and watering eye, blocked or running nostril, drooping eyelid, sometimes facial sweating or flushing.
The four conditions in the family are distinguished by how long each attack lasts and how often attacks occur:
Cluster headache — attacks of 15–180 minutes, 1–8 per day, in bouts lasting weeks to months
Paroxysmal hemicrania — shorter attacks of 2–30 minutes, more frequent (typically 5 or more per day), absolute response to indomethacin
Hemicrania continua — a continuous background one-sided headache lasting more than three months, with severe exacerbations and absolute response to indomethacin
SUNCT and SUNA — very brief stabbing attacks of seconds to a few minutes, sometimes more than 100 per day
The biology of the TAC family is centred on the hypothalamus — the brain’s circadian timekeeper — together with the trigeminal-autonomic reflex. This is why cluster attacks so often hit at the same time of day or night, and why bouts come at the same time of year.
II.
Cluster headache
Cluster headache is the most common and most extensively studied TAC. It is also one of the most painful conditions in medicine — consistently rated as more severe than childbirth or fracture by the people who experience it. The good news is that modern treatment is reliable and works quickly when it is set up properly.
The clockwork pattern
Cluster headache earns its name from its pattern. Attacks come in bouts — periods of weeks to a few months where attacks happen every day, sometimes several times a day — separated by remission periods of months to years where you are entirely free of headache. Within a bout, the attacks themselves show striking timing: many people are woken from sleep at almost the same time each night, often around 1–3 am, and bouts may recur at the same time of year (notoriously around equinoxes).
What an attack feels like
Severe to excruciating pain — usually described as boring, drilling or red-hot poker
Strictly one-sided — centred behind or around one eye, in the temple, or above the eyebrow
Lasting 15 to 180 minutes if untreated
1 to 8 attacks per day during a bout
On the painful side: a red and watering eye, a blocked or running nostril, a drooping eyelid (ptosis), sometimes a constricted pupil (miosis), facial sweating or flushing
Restlessness — pacing, rocking, banging the head against a wall — the opposite of the lie-still behaviour of migraine
Episodic vs chronic cluster headache
Episodic cluster headache — bouts last 7 days to 1 year, separated by remission of at least 3 months. Most people with cluster headache sit here.
Chronic cluster headache — attacks for more than 1 year without remission, or with remissions shorter than 3 months. This pattern is harder to treat and is one of the indications for advanced therapies.
Triggers within a bout
During a bout, the brain is in an unusually irritable state and triggers that are harmless between bouts will reliably set off an attack within minutes:
Alcohol — the classic trigger; an attack within an hour of a single drink. Outside a bout, alcohol does nothing.
Strong smells — solvents, perfume, petrol fumes
Vasodilators — nitrates, sildenafil and similar
Sleep — particularly REM sleep; the characteristic wake-up attack
III.
Paroxysmal hemicrania
Paroxysmal hemicrania (PH) is much less common than cluster headache and tends to look like a smaller, faster cousin: the same severe one-sided pain with autonomic features, but the attacks are shorter and more frequent.
Attacks lasting 2 to 30 minutes
Typically 5 or more attacks per day, often more
One-sided pain in the trigeminal distribution — usually around the eye, temple or forehead
Same autonomic features as cluster on the painful side
Episodic and chronic forms exist, similar to cluster
The defining feature: indomethacin response
What makes paroxysmal hemicrania a separate condition from cluster headache is its absolute response to indomethacin. At an adequate dose, indomethacin abolishes the headache. The response is part of the diagnostic criteria, not just a treatment option — if a TAC pattern doesn’t respond fully to indomethacin, the diagnosis is not paroxysmal hemicrania.
For this reason we often use a structured indomethacin trial both as a diagnostic test and as the start of treatment, with a stomach-protecting medication (a proton-pump inhibitor) added from day one.
IV.
Hemicrania continua
Hemicrania continua is a strictly one-sided headache that has been continuous for more than three months, with a mild-to-moderate baseline and periodic severe exacerbations that bring autonomic features on the painful side. Like paroxysmal hemicrania, it is defined by its absolute response to indomethacin.
Hemicrania continua is famously underdiagnosed. People are often treated for years as having chronic migraine, tension-type headache or cervicogenic headache before the diagnosis is made and the indomethacin trial is offered. The clinical clue is the strict one-sidedness without ever switching sides, and the pattern of a continuous low-level headache punctuated by sharper exacerbations with autonomic features.
Treatment is indomethacin in the same structured-trial pattern as paroxysmal hemicrania, with a proton-pump inhibitor for stomach protection. We try to identify the lowest dose that controls the headache, with periodic dose review.
V.
SUNCT and SUNA
SUNCT and SUNA are the rarest TACs and the most distinctive in shape: very brief stabbing or electric attacks, lasting from 1 second up to 10 minutes, with autonomic features on the painful side. Up to more than 100 attacks per day are possible.
SUNCT — Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing — both eye-redness and eye-watering present
SUNA — Short-lasting Unilateral Neuralgiform headache attacks with cranial Autonomic features — only one or neither of conjunctival injection and tearing is present
The attacks can resemble trigeminal neuralgia and may be triggered by light touch, chewing or wind on the face. The diagnostic separator is the presence of autonomic features in SUNCT/SUNA. Imaging is mandatory because the syndrome can be produced by structural lesions, particularly in the posterior fossa.
Acute treatment options are limited — the attacks are too short to abort with the usual acute medications. Treatment is preventive, and a sustained-release oral preventive (commonly lamotrigine, with topiramate or gabapentin as alternatives) is the mainstay.
VI.
Red flags — when it isn’t a TAC
Most one-sided headaches with autonomic features are a TAC. A minority are caused by something structural that mimics a TAC and needs urgent treatment in its own right. The features below should prompt further investigation:
Sudden onset — thunderclap headache reaching peak intensity within seconds; suspect subarachnoid haemorrhage until proven otherwise
Headache in pregnancy or postpartum — new or atypical headache here always needs same-day assessment
Cancer history, immunosuppression or HIV with a new headache pattern
Endocrine symptoms — new visual-field change, milky breast discharge, menstrual irregularity, change in libido or fatigue alongside the headache; raises the possibility of a pituitary lesion, several of which are recognised mimics of cluster and SUNCT-like syndromes
Any of these is a reason to be seen sooner rather than later, and may justify imaging that would not otherwise be needed. In TACs we have a low threshold for imaging from the first presentation regardless — see the next section.
VII.
How we diagnose at CURA
The diagnosis of a TAC is made clinically — on the pattern of the attacks, the autonomic features on the painful side, and the response to treatment — against the diagnostic criteria of the International Classification of Headache Disorders. There is no blood test that confirms it. The role of imaging is to exclude secondary causes.
The shape of a first consultation:
A structured history. The exact timing, duration, character, frequency and impact of attacks; autonomic features on the painful side; circadian and seasonal patterns; triggers; what you have tried; what worked, what didn’t; family history; comorbidities; current medications.
A neurological examination, where appropriate — what we look for depends on your presentation, but the point of it is to rule out signs of a secondary cause and document a normal baseline.
Review of your attack diary and any phone videos — if you have one of each, you have already done the largest part of the diagnostic work.
MRI brain — with dedicated pituitary views where appropriate. We arrange an MRI brain at first diagnosis of a TAC essentially without exception. Pituitary lesions, posterior-fossa pathology, vascular compression of the trigeminal nerve and other secondary causes can produce TAC-like syndromes that are clinically indistinguishable, and one early scan protects against years of mistaken diagnosis.
A structured indomethacin trial when paroxysmal hemicrania or hemicrania continua is on the table — with a proton-pump inhibitor for stomach protection. The response (or lack of one) is part of the diagnosis.
You leave the first consultation with a written plan: a likely diagnosis, an acute treatment that works for your attacks, a clear decision on whether you need a preventive (and if so, which one), a follow-up timeline, and an answer to the question you came in with.
VIII.
Treating an attack — acute therapy
Acute treatment differs sharply between the TAC subtypes. The summary below gives you the right starting point; the detail follows.
Cluster headache
The two most effective acute treatments for a cluster attack are high-flow oxygen and subcutaneous sumatriptan. Both work within roughly 15 minutes for most people who use them correctly.
Read the high-flow oxygen and sumatriptan SC detail ↓Hide ↑
High-flow oxygen. Delivered at 12–15 litres per minute through a non-rebreather mask, sitting upright, started at the very first sign of an attack. It aborts most cluster attacks within about 15 minutes, has essentially no systemic side effects, and can be used as often as attacks occur. The catch is logistical — you need an oxygen script, a cylinder at home, and a willingness to use the mask the moment an attack begins. Cylinders are arranged through Australian medical-gas suppliers (BOC, Air Liquide and similar) on the back of the script we provide; we walk you through the set-up at consultation.
Subcutaneous sumatriptan 6 mg by self-injection autoinjector is the other workhorse acute treatment. It aborts most attacks within 15 minutes. Oral or tablet triptans are too slow for cluster — the attack peaks in minutes, and an oral medication is just getting absorbed when the attack is at its worst. Intranasal zolmitriptan is an alternative for people who cannot or prefer not to inject. Subcutaneous sumatriptan is generally limited to two doses per 24 hours; if you need more than this, the right answer is to set up oxygen rather than stack triptan doses, and to revisit your preventive plan.
Triptans aren’t safe for everyone — particularly people with uncontrolled hypertension, ischaemic heart disease, prior stroke or transient ischaemic attack, peripheral vascular disease, or migraine with brainstem aura. We screen for this at consultation.
What we do not recommend. Simple analgesics (paracetamol, ibuprofen, codeine combinations) are essentially useless against a cluster attack; the attack peaks and resolves faster than they are absorbed. Opioids in any form are not indicated and risk medication-overuse headache and dependence.
Paroxysmal hemicrania and hemicrania continua
Acute treatment of individual attacks is rarely the focus — the headache is suppressed by indomethacin used continuously as a preventive, which is also the diagnostic test. See section IX.
SUNCT and SUNA
Individual attacks are too short to abort with conventional acute medications. Treatment is preventive — see section IX.
IX.
Preventing attacks
Preventive treatment is the heart of TAC care. The right preventive differs by subtype.
Cluster headache — verapamil first-line
Verapamil is the first-line preventive for both episodic and chronic cluster headache. It is started low and titrated up, and many patients need higher doses than are typically used in cardiology. Because verapamil can affect cardiac conduction, an ECG is performed before starting and at every dose increase — this is non-negotiable and is built into the plan.
Read the verapamil dosing, ECG monitoring and side-effect detail ↓Hide ↑
Starting dose is typically 80 mg three times a day, increased every 1–2 weeks against attack frequency and ECG findings. Many patients with episodic cluster respond within the 240–480 mg/day range; chronic cluster sometimes requires substantially higher doses, escalated cautiously with serial ECGs.
Side effects. Constipation is the commonest and usually manageable. Bradycardia, PR-interval prolongation and occasional heart-block are the reasons we monitor ECGs; ankle swelling, low blood pressure and gum hyperplasia are uncommon but recognised.
Verapamil is contraindicated in significant heart-block, severe bradycardia, decompensated heart failure and severe hypotension.
Cluster headache — transitional treatment
When a cluster bout is starting and verapamil hasn’t had time to take effect, a greater occipital nerve (GON) block is one of the most useful tools we have. It is a single in-rooms injection of local anaesthetic and a corticosteroid over the greater occipital nerve on the painful side, performed by Dr Ashraf at a follow-up procedure visit. Many patients see a meaningful drop in attack frequency for several weeks — enough to bridge until the preventive is working.
Short oral corticosteroid courses (a tapering course of prednisolone) are sometimes used as another transitional option while titrating verapamil; this is a discussion at consultation rather than a default.
Cluster headache — if verapamil isn’t enough
Where verapamil and transitional measures haven’t controlled attacks, second-line options include lithium (with appropriate baseline tests and serum-level monitoring) and topiramate. Each comes with its own monitoring and side-effect considerations, discussed at consultation.
Galcanezumab — one of the CGRP monoclonal antibodies, given as a monthly self-injection — has evidence for episodic cluster headache. In Australia it is not PBS-listed for cluster (its PBS indication is chronic migraine), so where it is appropriate for cluster it is prescribed on a private script and the patient pays the full cost, which is significant. We discuss this honestly at consultation; for many patients verapamil, transitional GON blocks and oxygen are the right plan and galcanezumab does not need to come into it.
Paroxysmal hemicrania and hemicrania continua — indomethacin
Both conditions are defined by their absolute response to indomethacin and treatment is therefore the same drug, used continuously, with stomach protection.
Read the indomethacin dosing and PPI detail ↓Hide ↑
Dosing is typically started low and titrated against the headache, with the goal of finding the lowest dose that controls symptoms. A short structured trial — building up over days and observing response — is what makes the diagnosis. Once the headache is suppressed, we identify the maintenance dose and review periodically.
Stomach protection. A proton-pump inhibitor (omeprazole, esomeprazole, pantoprazole or similar) is added from day one. Long-term indomethacin without a PPI is not safe.
Cautions and contraindications. Active peptic ulcer disease, significant kidney impairment, NSAID hypersensitivity, late pregnancy (third trimester — premature closure of the ductus arteriosus). Older patients and those with cardiovascular risk factors are reviewed individually.
SUNCT and SUNA — lamotrigine first-line
Lamotrigine is the most consistently effective oral preventive for SUNCT and SUNA. It is built up slowly from a low starting dose — the slow titration is essential to minimise the risk of serious skin rashes, including Stevens-Johnson syndrome — and the dose is then optimised against attack frequency. Topiramate and gabapentin are alternatives where lamotrigine is not tolerated.
X.
Pregnancy, life-stage and special situations
A few situations change the plan and are worth flagging at the time of booking.
Pregnancy and breastfeeding
Cluster headache often improves during pregnancy, although individual experiences vary. High-flow oxygen for attacks remains safe and is preferred to medication wherever possible. Subcutaneous sumatriptan has the most reassuring pregnancy-exposure data among the triptans; individual decisions are weighed against severity.
Verapamil use in pregnancy is individualised and should be discussed before conception where possible.
Indomethacin is generally avoided from around 30 weeks of pregnancy because of the risk of premature closure of the fetal ductus arteriosus. Use earlier in pregnancy is individualised in conjunction with obstetric medicine.
Lamotrigine is one of the better-studied preventives in pregnancy among the antiepileptics, but levels change across pregnancy and dose review is needed.
Please flag pregnancy or pregnancy planning at the time of booking so we can plan the consultation appropriately.
Older adults and cardiovascular comorbidity
Triptan choice (or avoidance) in cluster, NSAID safety in paroxysmal hemicrania and hemicrania continua, and verapamil dosing all change with cardiovascular history. Existing heart conditions, kidney function, and concurrent medications are reviewed at the first visit and shape the plan.
Cluster headache and sleep apnoea
Sleep apnoea is overrepresented in cluster headache and can aggravate nocturnal attacks. Where sleep apnoea is suspected, a sleep study is part of the workup; treating it can improve headache outcomes.
XI.
Living well with a TAC
A few practical things make a meaningful difference to outcome.
Set up oxygen at home if you have cluster headache. Have the cylinder, the mask, and the regulator before the next bout, not during it. Most patients describe this as the single most useful change they make.
Avoid alcohol during a bout. Outside a bout alcohol is fine; during a bout it is a near-guaranteed trigger and is best avoided altogether until the bout is over.
Protect sleep. Regular bed and wake times, consistent sleep duration, and treatment of any underlying sleep apnoea reduce attack frequency for many people.
Tell your dentist and your ENT specialist. Cluster pain is so often misdiagnosed as toothache or sinus disease that unnecessary procedures — root-canal treatments, tooth extractions, sinus surgery — are common. Knowing the diagnosis prevents this.
Don’t drive during an attack. Pull over safely and use your rescue treatment.
Keep an attack diary even when things are going well. Detecting a new bout early and pulling preventive treatment forward is one of the simplest wins available.
XII.
At your consultation
You will be seen by Dr Ashraf or another member of our neurology team for a structured first consultation in person at Drummoyne or Penrith. The first appointment focuses on getting the diagnosis right and starting an acute plan that works.
A typical first visit will include a structured history, a neurological examination where appropriate, review of any attack diary and phone videos you bring, and arrangement of an MRI brain if not already done. You leave with a written plan: a likely diagnosis, an acute treatment that works for your attacks, a decision on whether you need a preventive (and if so, which one and how it will be monitored), a follow-up timeline, and an answer to the question you came in with.
Greater occipital nerve blocks, when indicated, are arranged at a separate procedure visit with Dr Ashraf. Indomethacin trials and preventive titration are managed across the first follow-up visits and by phone where appropriate. Follow-up consultations can be telehealth, and many patients alternate in-person and telehealth from the second visit onwards.
Q&A
Frequently asked questions
+Is cluster headache the same as migraine?
No. They are different neurological conditions with different biology, different patterns and different treatments. Cluster attacks are shorter (15 minutes to 3 hours), almost always strictly one-sided, centred around or behind one eye, and come with autonomic features on the same side — a red watery eye, a blocked or running nostril, a drooping eyelid. Most people with cluster pace or rock during an attack rather than lying still (the opposite of migraine). Bouts come in clusters lasting weeks to months, often at the same time of year, and frequently wake people from sleep. Treatment overlaps in places (sumatriptan injection, occipital nerve blocks) but the cornerstones are different — high-flow oxygen and verapamil are central to cluster, neither is used for migraine.
+I get bouts of severe one-sided pain that come at the same time every year — is that cluster headache?
Possibly. The seasonal and circadian clockwork of cluster headache is one of its most striking features — bouts often arrive at the same time of year, attacks at the same time of day or night, frequently around 1–3 am. Plenty of conditions are misdiagnosed as cluster (and vice versa), so the diagnosis is made on the full pattern: severity, duration, autonomic features on the painful side, restlessness rather than wanting to lie still, and exclusion of secondary causes on imaging. We routinely arrange an MRI brain at first diagnosis of any TAC.
+I have a one-sided headache 24 hours a day — is that hemicrania continua?
It might be. Hemicrania continua is a strictly one-sided continuous headache lasting more than three months, usually mild-to-moderate at baseline with periodic severe exacerbations and autonomic features. It is famously underdiagnosed — many people are treated for years as chronic migraine before the diagnosis is made. The defining feature is an absolute response to indomethacin: at the right dose, indomethacin abolishes the headache. We often use a structured indomethacin trial as both the diagnostic test and the start of treatment, with a stomach-protecting medication added.
+Will I need an MRI?
Yes — almost always. Unlike migraine, which is usually a clinical diagnosis without imaging, every first-time TAC presentation at CURA is investigated with an MRI brain (with dedicated pituitary views where appropriate). The reason is that pituitary lesions, posterior-fossa pathology, vascular compression of the trigeminal nerve and other secondary causes can produce TAC-like syndromes that are clinically indistinguishable. One scan, early, protects you against years of mistaken diagnosis.
+Is high-flow oxygen really effective for cluster headache?
Yes — for the right patient, oxygen aborts most attacks within around 15 minutes when delivered correctly: 12–15 litres per minute through a non-rebreather mask, sitting upright. It is one of the most effective acute treatments in neurology and has essentially no systemic side effects. The catch is logistical: you need a script, a cylinder at home, and the willingness to use it the moment an attack begins. We help you set this up and walk you through how to use it.
+Is galcanezumab covered by the PBS for cluster headache?
No. Galcanezumab (Emgality) is PBS-subsidised in Australia for chronic migraine when eligibility criteria are met, but it is not PBS-listed for episodic or chronic cluster headache. Where galcanezumab is appropriate for cluster, it is prescribed on a private script and you pay the full cost — which is significant. We discuss this honestly at consultation; for many patients verapamil, transitional GON blocks and oxygen are the right plan and galcanezumab does not need to come into it.
+Are TACs hereditary?
There is a familial element to cluster headache — first-degree relatives carry a higher risk than the general population, though most people with cluster headache have no affected relative. Paroxysmal hemicrania, hemicrania continua and SUNCT/SUNA are not strongly heritable in the way that migraine is. Genetic testing is not part of routine TAC diagnosis.
+Can I have a telehealth appointment?
Your first TAC consultation is in person. The neurological examination is part of how we exclude secondary causes, and a video call cannot substitute for it. Follow-up consultations can be telehealth, and many patients alternate in-person and telehealth from the second visit onwards. Greater occipital nerve blocks and any procedural visits are always in person.
Directory
For referring GPs
What we manage
New and established cluster headache — episodic and chronic; verapamil titration with ECG monitoring; transitional greater occipital nerve blocks in-rooms; oxygen scripting; second-line preventives (lithium, topiramate); private-script galcanezumab where appropriate.
Paroxysmal hemicrania and hemicrania continua — structured indomethacin trial as diagnostic test and treatment, with PPI cover; long-term dose review.
SUNCT and SUNA — lamotrigine titration with appropriate rash counselling; topiramate or gabapentin where lamotrigine is not tolerated.
Mixed-picture or diagnostically uncertain headache where TAC features are present alongside migraine or new daily persistent headache — differential workup including imaging.
Autonomic features on the painful side — conjunctival injection, lacrimation, nasal congestion / rhinorrhoea, ptosis/miosis, facial sweating
Behaviour during attack: restless and pacing vs lying still
Every preventive and abortive tried: agent, dose, duration and reason for stopping
Any phone video of an attack — transformative
Existing imaging if available; we do not generally ask the referrer to organise an MRI in advance
Cardiovascular history (relevant to verapamil and triptans), renal function and GI history (relevant to indomethacin), pregnancy status / planning
Investigation pathway
MRI brain (with pituitary views where indicated) is arranged from our clinic for essentially every first-time TAC presentation. Where the picture is suggestive of SUNCT/SUNA, dedicated views of the trigeminal nerve and posterior fossa are requested.
Bloods (FBE, U&E, LFTs, ESR/CRP) where second-line preventives or older-patient atypical TAC pictures are in play.
How to refer
Phone reception: (02) 7906 8356 — ask for the headache clinic to flag urgency or confirm current referral channels (fax, HealthLink, Argus, secure-messaging or e-referral). Standard referrals by mail or secure messaging are accepted.
Routine new-TAC consultations are typically scheduled within a few weeks; active cluster bouts and other clinically urgent presentations (suspected secondary cause, fulminant pattern, post-hospital follow-up) are triaged sooner — phone reception and flag the clinical urgency.
Telehealth follow-up is offered where appropriate; the first consultation is in person (neurological examination required to exclude secondary causes). GON blocks and any procedural visits are always in person.
Letter back to you
Our service standard: a GP letter within five business days of consultation — with diagnosis, plan, prescriptions issued, monitoring requirements (ECG schedule for verapamil; PPI cover for indomethacin; rash counselling for lamotrigine), follow-up timeline, and explicit shared-care actions for you.
Directory
Patient resources
Australian organisations
Headache Australia — the patient-advocacy program of the Brain Foundation, with practical information on cluster headache and other primary headaches.
Brain Foundation — broader neurology information, including TACs.
healthdirect Australia — government-funded health information and 24/7 nurse advice line on 1800 022 222.
Clusterbusters — US-based patient organisation. Educational content only; treatment advice from the website should not substitute for the plan agreed with your neurologist.
Headache-tracking apps
Migraine Buddy — despite the name, it works well for tracking cluster bouts and other TAC patterns; exports a report you can bring to consultation.
