The head is one of the most common sites of pain in the body.
The most common types of headache can be classified as 1) primary, 2) secondary, and 3)
cranial neuralgias, facial pain, and other headaches.
The most common types of primary headaches are 1) tension, 2) migraine, and 3) cluster.
Tension headaches are the most common type of primary headache and usually are treated
with over-the-counter (OTC) medications for pain.
Secondary headaches are a symptom of an injury or an underlying illness.
Patients should seek medical care for new onset headaches, fever,stiff neck, change in
behavior,vomiting, weakness, or change in sensation.
What is a headache?
Headache is defined as a pain arising from the head or upper neck of the body. The pain originates
from the tissues and structures that surround the brain because the brain itself has no nerves that
give rise to the sensation of pain (pain fibers). The periosteum that surrounds bones; muscles that
encase the skull, sinuses, eyes, and ears; and meninges that cover the surface of the brain and
spinal cord, arteries, veins, and nerves, all can become inflamed or irritated to cause the pain of a
headache. This pain may be a dull ache, sharp, throbbing, constant, mild, or intense
How are headaches classified?
In 2005, the International Headache Society released its latest classification system for headache.
Because so many people suffer from headaches and because treatment sometimes is difficult, it
was hoped that the new classification system would help health care professionals make a specific
diagnosis as to the type of headache and allow better and more effective options for treatment.
There are three major categories of headache based upon the source of the pain:
1. primary headaches;
2. secondary headaches; and
3. cranial neuralgias, facial pain, and other headaches.
What are primary headaches?
Primary headaches include migraine, tension, and cluster headaches, as well as a variety of other
less common types of headache.
Tension headaches are the most common type of primary headache. Tension headaches
occur more commonly among women than men. According to the World Health Organization, 1
in 20 people in the developed world suffer with a dailytension headache.
Migraine headaches are the second most common type of primary headache. An estimated 28
million people in the United States (about 12% of the population) will experience a migraine
headache. Migraine headaches affect children as well as adults. Before puberty, boys and girls
are affected equally by migraine headaches, but after puberty, more women than men are
affected. It is estimated that 6% of men and up to 18% of women will experience a migraine
headache in their lifetime.
Cluster headaches are a rare type of primary headache affecting 0.1% of the population (1 in a
1,000 people). It more commonly affects men in their late 20s though women and children can
also suffer this type of headache.
Primary headaches can affect the quality of life. Some people have occasional headaches that
resolve quickly while others are debilitated. While these headaches are not life-threatening, they
may be associated with symptoms that can mimic strokes.
Many patients equate severe headache with migraine, but the amount of pain does not determine
the diagnosis of migraine. A full discussion of migraine headaches can be found in this article.
What are secondary headaches?
Secondary headaches are those that are due to an underlying structural problem in the head or
neck. This is a very broad group of medical conditions ranging from dental pain from infected teeth
to pain from an infected sinus, to life-threatening conditions like bleeding in the brain or infections
like encephalitis or meningitis.
Traumatic headaches fall into this category including post-concussion headaches.
This group of headaches also includes those headaches associated with substance abuse and
excess use of medications used to treat headaches (rebound headaches).
What are cranial neuralgias, facial pain, and other headaches?
Neuralgia means nerve pain (neur= nerve + algia=pain). Cranial neuralgia describes inflammation of
one of the 12 nerves that supply the motor and sensation function of the head and neck. Perhaps
the most commonly recognized example is trigeminal neuralgia, which affects cranial nerve V (the
trigeminal nerve) and can cause intense facial pain.
What causes tension headaches?
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While tension headaches are the most frequently occurring type of headache, their cause is not
known. The World Health Organization estimates that in the developed world, 80% of women and
67% of men will experience this type of headache. The most likely cause is contraction of the
muscles that cover the skull. When the muscles covering the skull are stressed, they may become
inflamed, go into spasm, and cause pain. Common sites include the base of the skull where the
trapezius muscles of the neck insert, the temples where muscles that move the jaw are located, and
There is little research to confirm the exact cause of tension headaches. Tension headaches occur
because of physical or emotional stress placed on the body. For example, these stressors can cause
the muscles surrounding the skull to clench the teeth and go into spasm. Physical stressors include
difficult and prolonged manual labor, or sitting at a desk or computer for long periods of time
concentrating. Emotional stress also may cause tension headaches by causing the muscles
surrounding the skull to contract.
What are the symptoms of tension headaches?
Common presentation of tension headaches includes the following:
Pain that begins in the back of the head and upper neck and is described as a band-like
tightness or pressure. It may spread to encircle the head.
The most intense pressure may be felt at the temples or over the eyebrows.
The pain can vary in intensity but usually is not disabling, meaning that the sufferer may
continue with daily activities. The pain usually is bilateral (affecting both sides of the head).
The pain is not associated with an aura (see below), nausea, vomiting, or sensitivity to light and
The pain occurs sporadically (infrequently and without a pattern) but can occur frequently and
even daily in some people.
The pain allows most people to function normally, despite the headache.
How are tension headaches diagnosed?
The key to making the diagnosis of any headache is the history given by the patient. The health care
professional will ask questions about the headache to try to help make the diagnosis. Those
questions may include learning about the quality, quantity, and duration of the pain, and asking
about any associated symptoms. The person with a tension headache will usually complain of pain
that is mild-to-moderate, located on both sides of the head, described as a tightness that is not
throbbing, and not made worse with activity. There will be no associated symptoms like nausea,
vomiting, or light sensitivity.
The physical examination, particularly the neurologic portion of the examination, is important in
tension headaches because to make the diagnosis, it should be normal. However, there may be
some tenderness of the scalp or neck muscles. If the health care professional finds an abnormality
on neurologic exam, then the diagnosis of tension headache should be put on hold while the
potential for other causes of headaches has been investigated.
How are tension headaches treated?
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Tension headaches are painful, and patients may be upset that the diagnosis is "only" a tension
headache. Even though it is not life-threatening, a tension headache can make daily activities more
difficult to accomplish. Most people successfully treat themselves with over-the–counter (OTC) pain
medications to control tension headaches. The following work well for most people:
ibuprofen (Motrin, Advil),
acetaminophen (Tylenol), and
If these fail, other supportive treatments are available. Recurrent headaches should be a signal to
seek medical help. Massage, biofeedback, and stress management can all be used as adjuncts to
help with control of tension headaches.
It is important to remember that OTC medications, while safe, are medications and may have side
effects and potential interactions with prescription medications. It always is wise to ask a health care
professional or pharmacist if one has questions about OTC medications and their use. This is
especially important with OTC pain medications, because they are used so frequently.
It is important to read the listing of ingredients in OTC pain medications. Often an OTC medication is
a combination of ingredients, and the second or third listed ingredient may have the potential for
drug interaction or contraindication based upon a patient's other medical issues For example:
Some OTC medications includecaffeine, which may trigger rapid heartbeats in some patients.
In night time preparations,diphenhydramine (Benadryl) may be added. This may cause
sedation, and driving or using heavy machinery may not be appropriate when taking a sedative
Other examples where caution should be used include the following:
Aspirin should not be used in children and teenagers because of the risk of Reye's Syndrome, a
life threatening complication that may occur when a viral infection is present and aspirin is
Aspirin, ibuprofen, and naproxen are irritating to the stomach and may cause intestinal
bleeding. They should be used with caution in patients who have peptic ulcer disease or who
take blood thinners like warfarin(Coumadin), dabigatran (Pradaxa), clopidogrel bisulfate
(Plavix), and prasugrel (Effient).
Overuse of aspirin, ibuprofen, and naproxen also may cause kidney damage.
Acetaminophen, if used in large amounts, can cause liver damage or failure. It should be used
with caution in patients who drink significant amounts of alcohol or who have liver disease.
One cause of chronic tension headaches is overuse of medications for pain. When pain
medications are used for a prolonged period of time, headaches can recur as the effects of the
medication wear off (This is classified as a secondary headache when the pain is due to the
withdrawal of a medication [rebound headache].).
What causes cluster headaches?
Cluster headaches are so named because they tend to occur daily for periods of a week or more
with long periods of time, months to years, with no headache symptoms. They occur at the same
time of day, often waking the patient in the middle of the night.
The cause of cluster headaches is uncertain but may be due to a sudden release of the chemicals
histamine and serotonin in the brain. The hypothalamus, an area located at the base of the brain, is
responsible for the body's biologic clock and may be the location that is the source for this type of
headache. When brain scans are performed on patients who are in the midst of a cluster headache,
abnormal activity has been found in the hypothalamus.
Cluster headaches also:
tend to run in families and this suggests that there may be a role for genetics;
may be triggered by changes in sleeppatterns; and
may be triggered by medications (for example, nitroglycerin, used for heart disease).
If an individual is in a susceptible period for cluster headache, cigarette smoking, alcohol, and some
foods (for example, chocolate and foods high in nitrites like smoked meats) also can be potential
causes for headache.
What are the symptoms of cluster headaches?
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Cluster headaches are headaches that come in groups (clusters) separated by pain-free periods of
months or years. A patient may experience a headache on a daily basis for weeks or months and
then be pain free for years. This type of headache affects males more frequently and often begins in
adolescence but can extend to those in middle age.
During the period in which the cluster headaches occur, pain typically occurs once or twice
daily, but some patients may experience pain more than twice daily.
Each episode of pain lasts from 30 to 90 minutes.
Attacks tend to occur at about the same time every day and often awaken the patient at night
from a sound sleep.
The pain typically is excruciating and located around or behind one eye.
Some patients describe the pain as feeling like a hot poker in the eye. The affected eye may
become red, inflamed, and watery.
The nose on the affected side may become congested and runny.
Unlike patients with migraine headaches, patients with cluster headaches tend to be restless. They
often pace the floor, bang their heads against a wall, and patients can be driven to desperate
measures including contemplating suicide.
How are cluster headaches diagnosed?
The diagnosis of cluster headache is made by taking the patient's history. The description of the pain
and its clock-like recurrence is usually enough to make the diagnosis.
If examined in the midst of an attack, the patient usually is in a painful crisis and may have the eye
and nose watering as described previously. If the patient is seen when the pain is not present, the
physical examination is normal and the diagnosis will depends upon the history.
How are cluster headaches treated?
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Cluster headaches may be very difficult to treat, and it may take trial and error to find the specific
treatment regimen that will work for each patient. Since the headache recurs daily, there are two
treatment needs. The pain of the first episode needs to be controlled, and the following headaches
need to be prevented.
Initial treatment options may include one or more of the following:
inhalation of high concentrations of oxygen (though this will not work if the headache is well
injection of triptan medications, like,sumatriptan (Imitrex), zolmitriptan(Zomig), and rizatriptan
(Maxalt) which are common migraine medications;
injection of lidocaine, a local anesthetic, into the nostril;
dihydroergotamine (DHE, Migranal), a medication that causes blood vessels to constrict; and
Prevention of the next cluster headache may include the following:
calcium channel blockers (for example,verapamil [Calan, Verelan, Verelan PM, Isoptin, Covera-
HS], diltiazem[Cardizem, Dilacor, Tiazac]);
prednisone (Deltasone, Liquid Pred);
lithium (Eskalith, Lithobid); and
antiseizure medications including valproic acid, divalproex (Depakote, Depakote ER, Depakene,
Depacon), and topiramate (Topamax).
Can cluster headaches be prevented?
Since cluster headache episodes may be spaced years apart, and since the first headache of a new
cluster episode can't be predicted, daily medication may not be warranted.
Lifestyle changes may help minimize the risk of a cluster headache flare. Stopping smoking and
minimizing alcohol may prevent future episodes of cluster headache.
What diseases cause secondary headaches?
Headache is a symptom associated with many illnesses. While head pain itself is the issue with
primary headaches, secondary headaches are due to an underlying disease or injury that needs to
be diagnosed and treated. Controlling the headache symptom will need to occur at the same time
that diagnostic tests are being considered to diagnose the underlying disease. Some of the causes
of secondary headache may be potentially life-threatening and deadly. Early diagnosis and
treatment is essential if damage is to be limited.
The International Headache Society lists eight categories of secondary headache. A few examples
in each category are noted (This is not a complete list.).
Head and neck trauma
Injuries to the head may cause bleeding in the spaces between the layers of tissue that
surround the brain (subdural, epidural, and subarachnoid spaces) or within the brain tissue itself
(intracerebral hemorrhage: intra=within + cerebral=brain, hemorrhage=bleeding).
Edema or swelling within the brain, not associated with bleeding, may cause pain and a change
in mental function.
Concussions, where head injury occurs without bleeding. Headache is one of the hallmarks of
Whiplash and neck injury also cause head pain.
Blood vessel problems in the head and neck
Stroke or transient ischemic attack (TIA)
Arteriovenous malformations (AVM) may cause headache before they leak.
Cerebral aneurysm and subarachnoid hemorrhage. An aneurysm, or a weakened area in a
blood vessel wall, can expand and leak a small amount of blood causing what is called a
sentinel headache. This may be a warning sign of a future catastrophic bleed into the brain.
Carotid artery inflammation
Temporal arteritis (inflammation of the temporal artery)
Non-blood vessel problems of the brain
Brain tumors, either primary, originating in the brain, or metastatic from a cancer that began in
Idiopathic intracranial hypertension, historically called pseudotumor cerebri, where pressure
within the spinal canal increases. The cause is unknown and while it can occur in all ages, it
often affects young, obese females. Idiopathic intracranial hypertension can cause significant
headache and if left untreated may, on occasion, lead toblindness.
Medications and drugs (including withdrawal from those drugs)
Systemic infections (for example, pneumonia or influenza)
Changes in the body's environment
High blood pressure (hypertension)
Problems with the eyes, ears, nose throat, teeth, sinuses, and neck
How are secondary headaches diagnosed?
If there is time, the diagnosis of secondary headache begins with a complete patient history followed
by a physical examination and laboratory and radiology tests as appropriate.
However, some patients present in crisis with a decreased level of consciousness or unstable vital
signs. In these situations, the health care professional may decide to treat a specific cause without
waiting for tests to confirm the diagnosis.
For example, a patient with headache, fever, stiff neck, and confusion may have symptoms that
suggest meningitis. Since meningitis can be rapidly fatal, antibiotic therapy may be started before
blood tests and a lumbar puncture are performed to confirm the diagnosis. It may be that the
diagnosis is found to be a brain tumor or subarachnoid hemorrhage, but the benefit of early
antibiotics outweighs the risk of not giving them promptly.
What are the exams and tests for secondary headaches?
The patient history and physical examination provide the initial direction for determining the cause of
secondary headaches. Therefore, it is extremely important that a patient with new, severe headache
seeks medical care and gives their health care professional an opportunity to assess their condition.
Tests that may be useful in making the diagnosis of the underlying disease causing the headaches
will depend upon the doctor's evaluation and what specific disease, illness, or injury is being
considered as the cause of the headaches (the differential diagnosis). Common tests that are
considered include the following:
computerized tomography (CT scan);
magnetic resonance imaging (MRI) scans of the head; and
lumbar puncture (spinal tap).
Specific tests will depend upon what potential issues the health care professional and patient want to
Blood tests provide helpful information in association with the history and physical examination in
pursuing a diagnosis. For example, an infection or inflammation in the body may cause a rise in the
white blood cell count, the erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP). These
two tests are very nonspecific; that is, they may be abnormal with any infection or inflammation, and
abnormalities do not point to a specific diagnosis of the cause of the infection or inflammation. The
ESR is often used to make the tentative diagnosis of temporal arteritis, a condition that affects an
older patient, usually over the age of 65, who presents with a sharp, stabbing temporal headache.
Blood tests may be used to assess electrolyte disturbances, and a variety of organ dysfunctions
including liver, kidney, and thyroid.
Toxicology tests may be helpful if the patient is suspected of abusing alcohol, prescription, or other
drugs of abuse.
Computerized tomography of the head
Computerized tomography (CT scan) is able to detect bleeding, swelling, and some tumors within
the skull and brain. It can also show evidence of previous stroke. With intravenous contrast injection,
it may also be used to look at the arteries of the brain.
Magnetic resonance imaging (MRI) of the head
MRI is able to better look at the anatomy of the brain and meninges (the layers that cover the brain
and the spinal cord). While it is more precise, the time to perform the scan is significantly longer than
for computerized tomography. This type of scan is not available at all hospitals. Moreover, it takes
much longer to perform, requires the patient to cooperate by holding still, and requires that the
patient have no metal in their body (for example, a heart pacemaker or metal foreign objects in the
Cerebrospinal fluid, the fluid that surrounds the brain and spinal cord, can be obtained with a needle
that is inserted into the spine in the lower back. Examination of the fluid looks for infection (such as
meningitis due to bacteria, virus, fungus, or tuberculosis) or blood from hemorrhage. In almost all
cases, computerized tomography is done prior to lumbar puncture to make certain there is no
bleeding, swelling, or tumor within the brain. Pressure within the space can be measured when the
lumbar puncture needle is inserted. Elevated pressures may make the diagnosis of idiopathic
intracranial hypertension in combination with the appropriate history and physical examination.
When should I seek medical care for a headache?
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A patient should seek medical care if their headache is:
The "worst headache of your life." This is the wording often used in textbooks as a cue for
medical practitioners to consider the diagnosis of a subarachnoid hemorrhage due to a ruptured
cerebral aneurysm. The amount of pain will often be taken in context with the appearance of the
patient and other associated signs and symptoms. Too often, patients are prompted to use this
expression by a health care professional and do not routinely volunteer the phrase.
Different than their usual headaches
Starts suddenly or is aggravated by exertion, coughing, bending over, or sexual activity
Associated with persistent nausea and vomiting
Associated with fever or stiff neck. A stiff neck may be due to meningitis or blood from a
ruptured aneurysm. However, most patients who complain of a stiff neck have muscle spasm
and inflammation as the cause.
Associated with seizures
Associated with recent head trauma or a fall
Associated with changes in vision, speech, or behavior
Associated with weakness or change in sensation on one side of their body that may be a sign
Not responding to treatment and is getting worse
Requires more than the recommended dose of over-the-counter medications for pain
Disabling and interfering with work and quality of life