Headache overview

What is it?

Headaches can be divided into two main types: primary headache and secondary headache.

Primary headache includes

• tension-type headaches
• migraines
• cluster headaches.

Typically, tension-type headaches cause mild to moderate pain, usually on both sides of the head. There is a pressing or tightening sensation. It is not pulsating and is not accompanied by nausea. The headache does not get worse with routine physical activity.

The typical migraine headache is throbbing or pulsating, and often is associated with nausea and changes in vision. While many migraine headaches are severe, not all severe headaches are migraines, and some episodes of migraine can be quite mild. Most people who have migraine experience repeated attacks of headaches that occur over many years.

Cluster headaches are very intense headaches. They usually start in the area around one eye, then spread to nearby areas of the face. Each headache lasts about a half-hour to three hours. Episodes can occur several times over 24 hours (in clusters). This happens daily, lasting several weeks to months. Cluster headaches are much more likely to happen in men than women.

There are many potential reasons for secondary headache. Here are some examples:

• trauma or injury to the head or neck
• blood vessel disorders in the head or neck, such as a brain aneurysm, a carotid artery tear, or inflammation (temporal arteritis)
• infection, such as meningitis or encephalitis
• medication related. The medication may be the direct cause of headaches. For example, headache is a side effect of the blood pressure medicine nifedipine.
• withdrawal headache. Headaches can occur when a substance or medication is suddenly stopped. Examples include caffeine-withdrawal headache or headache after abruptly stopping long-term use of pain relievers.

Symptoms

By definition, a headache is a pain in the head. But the type, location, and severity of pain are highly variable. And for migraine, there can be profound symptoms without a headache.

A person can simultaneously have multiple reasons for headaches. It's common for a person to have both migraine and tension-type headaches. And the symptoms of tension-type headaches and migraine headaches can overlap. For example, both types of headaches may be made worse by bright lights or loud noises.

In general, migraine headaches tend to throb. Tension-type headaches tend to cause a more constant pain. But the pain of either a migraine or a tension-type headache can be steady or throbbing, or can alternate between the two.

Diagnosis

Most often, people can make a self-diagnosis of a tension-type headache or migraine. However, the onset of a new, very severe headache should prompt an urgent visit for clinical evaluation. The doctor will often be able to make the diagnosis based on your description of the headache, your medical history, and the results of a physical examination.

A computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of the head may be ordered. These imaging tests may be used to investigate headache pain that is associated with unexpected or unusual symptoms.

Expected duration

Headaches can last from a few minutes to an entire day, and even for many consecutive days.

A chronic headache or persistent migraine can last for part or all of the day for most days of the week. The pain can also be continuous. The intensity of pain may fluctuate during that time.

Prevention

Relaxation techniques and avoidance of stressful situations may help to prevent headaches. Many things can trigger a headache. Identifying and correcting one or more triggers may reduce headache frequency and severity.

People with frequent or severe migraine attacks often benefit from taking preventive medication daily. Examples include

• beta blockers, such as propranolol (Inderal) or nadolol (Corgard)
• calcium-channel blockers, such as verapamil (Calan, Isoptin)
• anticonvulsants, such as valproate (Depakote, other brand names) or topiramate (Topamax)
• tricyclic antidepressants, such as amitriptyline (Elavil) or venlafaxine (Effexor).

Treatment

For infrequent headaches, over-the-counter pain relievers are convenient, effective, and relatively safe. Examples include aspirin, acetaminophen (Tylenol), ibuprofen (Advil, Motrin), and naproxen (Aleve). Some people get more pain relief with combination pain relievers that contain caffeine.

To be most effective, a pain-reliever medicine should be taken immediately when the headache starts.

The use of any over-the-counter pain reliever should be limited to no more than two or three days per week. If pain medications are used more frequently than that, "rebound" headaches may occur on the days that medications are not taken.

To abort a migraine, several prescription drugs are available:

• isometheptene (Midrin and other brand names)
• triptans, such as sumatriptan (Imitrex), naratriptan (Amerge), zolmitriptan (Zomig), and rizatriptan (Maxalt)
• ergotamines, such as sublingual ergotamine (Ergomar) and dihydroergotamine (Migranal).

In addition, people who experience nausea with a migraine (with or without vomiting) can also take an anti-nausea pill or suppository.

Frequent episodic and chronic headaches are more difficult to treat. Rebound headaches are common when pain relievers are stopped. Therapy to prevent the headache before it starts is a better strategy than taking pain relievers after the headache is present. There are several medications that can break the cycle of recurrent headaches, such as naproxen (Naprosyn, Aleve, generic versions) and amitriptyline (Elavil, generic versions).

Some people are able to treat their headaches without medications. You can apply an ice pack or heating pad to any tight areas in the neck and shoulders. You can also try massaging the area.

When to call a professional

Most headaches are harmless. It's reassuring if you are able to relieve your headaches without medications or with only occasional use of a pain reliever.

Headaches are rarely caused by a serious medical problem. However, you should call or visit your doctor if you have

• a headache that occurs after a head injury
• a headache accompanied by fever or vomiting
• a headache associated with
  • blurred vision
  • difficulty speaking
  • numbness or weakness of the arms or legs
• headaches that are increasing in intensity or frequency over time
• a very severe headache that comes on suddenly (andquot;thunderclap" headache) or headache associated with loss of consciousness
• headaches that require daily use of pain-relieving medications.

Prognosis

Infrequent episodic headaches can usually be treated successfully with pain-relieving medication. But finding the right combination of therapies to relieve frequent episodic and chronic headaches may take several months. Over time, most people will have fewer and less severe headaches.

Additional info

National Institute of Neurological Disorders and Stroke
www.ninds.nih.gov/

National Headache Foundation
https://www.headaches.org/

American Migraine Foundation
https://americanmigrainefoundation.org