The patient should be treated with verapamil for episodic cluster headache. He experiences one or two daily attacks of severe, unilateral, periorbital pain lasting 2 to 3 hours if untreated that is accompanied by at least one ipsilateral cranial autonomic feature, such as ptosis, tearing, or rhinorrhea; he also exhibits motor restlessness during headache episodes. These features meet International Headache Society criteria for cluster headache. Cycles of cluster headache can last weeks to months, with attack frequency varying from 1 event every other day to 8 per day. Cluster headache typically affects young and middle-aged adults. Male sex and tobacco use are risk factors.

Oxygen therapy and subcutaneous sumatriptan are the most effective acute cluster headache treatments. Glucocorticoids can help reduce attack frequency and are effective as a bridge therapy to longer-term prophylactic agents. Verapamil is the drug of choice for cluster headache prevention. Because relatively high doses are sometimes required, regular electrocardiographic assessment for potential prolongation of the P-R interval or heart block is recommended.

Both amitriptyline and propranolol are effective agents for prevention of migraine but not cluster headache. The duration of the headaches described by this patient is too short to meet criteria for migraine.

Indomethacin is an effective treatment for chronic paroxysmal hemicrania (CPH) but not cluster headache. CPH also is characterized by repetitive episodes of unilateral pain with ipsilateral autonomic features but occurs at least 5 times daily with a typical duration between 3 and 20 minutes.

Anticonvulsants, such as topiramate, have limited effectiveness in cluster headache prevention and should be considered only after verapamil therapy proves ineffective or is poorly tolerated.