A headache is pain located in the head, upper neck and behind the ears. Ninety-five percent of all adults are likely to have at least one headache per year. Localized and severe pain in the head causes 2 percent of emergency room visits. Headache is a common and sometimes chronic disorder for 20% of the population. Laboratory tests are not necessary to make a clinical diagnosis. Headaches are often benign and respond to treatment. However, physicians regard headaches as having a high suspicion for life threatening diseases.
Many Types of Headaches
One hundred different subtypes of headache can make identifying persistent headache difficult. Episodic headaches happen infrequently. The most common type of headache is a migraine headache. Ten to twelve percent of the population has this type of recurring and chronic headache. Migraine sufferers have a special name, “migraineurs.”
Women are three times more likely than men to have migraines. Migraines sufferers can have severe, debilitating and painful headache episodes. Headaches can have stages, and change in severity and frequency. Episodic headaches can become sporadic and then turn persistent and chronic. However, headache rarely causes permanent disability.
Daily life is disrupted for headache sufferers. Headache patients are usually between the ages of 25 and 55, which is often a person’s most productive time of life. Headaches, especially chronic headaches, decrease productivity with significant lost time from work. Migraine sufferers are less likely to hold full time jobs, with resulting lower level of household income. Migraine sufferers experience stigma similar to those with HIV, mental illness, and cancer. Migraine patients can become depressed and anxious when coping with their headaches and the demands of life.
Individuals cannot function well at home or work. Families, businesses, and health care systems suffer from the impact of headaches. The American Academy of Neurology estimates that over 150 million workdays are lost each year due to migraine headaches. These lost workdays have a monetary value estimated at 13 billion dollars for American employers. The burden worldwide for employers is similar. The World Health Organization (WHO) finds difficulty in estimating headache figures in underdeveloped countries. Underdeveloped countries have higher priorities than headaches in their often rural populations and have limited funds for population studies. In developed countries, the WHO estimates 3000 migraine attacks occur every day for each million of the general population.
Episodic and chronic headaches may have long-term consequences with progressive diminishment in cardiovascular and neurologic health. Coping with a chronic headache disorder over the long-terms may predispose the individual to other illnesses. Serious health problems include:
- Pulmonary system – asthma, bronchitis, and chronic obstructive pulmonary disease patients also have headaches. Headaches cause nerve cell excitation that inhibits the pulmonary system. Pulmonary and bronchial circulation suffers from the disturbances upstream in the pathway.
- Cardiovascular Disease – the frequency of migraines indicates an increased risk for heart problems. Women who had weekly migraines were 3 times more likely to have a stroke, particularly ischemic stroke. Women, who had migraines more than once a month, were one ½ times more likely to have heart problems. The risk of stoke for most headache patients is low, however.
- Sensitivity – headaches patients, especially migraine sufferers, experience pain and discomfort in daily living. Combing the hair, rubbing the head, putting on makeup, putting on clothes and jewelry, and eating may become painful.
- Psychiatric – Headache and migraine patients have a 50% greater chance of developing depression, panic and suicidal ideation. Migraine patients with aura, or the warning feeling that precedes a migraine, were even more likely to have psychiatric disorders. Teenagers with migraine aura considered suicide 6 times more often than the general population.
Headache is treatable but often people do not seek medical treatment for a variety of reasons. Over the counter medications are widely available and utilized by most headache sufferers. Headache sufferers do not always have medical insurance, medical services or simply to do not ask for help. Non–insured sufferers are the most likely to receive no care or substandard care. Those on Medicaid or limited insurance are also likely to receive substandard care, as often they seek help in the emergency room and not the doctor’s office. Insured individuals who choose not to seek medical treatment most often have tension headaches, migraines without aura, less intense headaches, and less frequent headaches.
Common Subtype Headaches
Primary headache disorders are 1) Migraine headache 2) Tension headache and 3) Cluster headache.
Headache that is chronic or episodic usually happens between the ages of 25-55 years old. This neurological disorder transforms daily living once or more than 15 times per month. Migraine subdivides into 1) migraine without aura and 2) migraine with aura. Most patients with migraine do not have aura, a visual, auditory, language or sensation dysfunction that precedes or accompanies the migraine. Lights, sounds, and patterns can appear suddenly and act to warn of an impending episode. Physical symptoms may also be present, including abdominal pain, nausea and vomiting. Migraine with aura occurs for about 1/3 of migraine sufferers.
2) Tension Type Headache (TTH)
The most common kind of headache is Tension-type headache (TTH). Many times a person may complain of a headache that could be due to a variety of conditions including insomnia, hypothyroidism or high blood pressure. Diagnosis of tension headache relies on the exclusion of any possible causes of the headache. A medical history and evaluation of symptoms can rule out other causes and in favor of TTH. TTH episodes can last for minutes and even weeks at a time. The pain is usually mild or moderate and spreads evenly in location. Exercise or physical exertion does not usually worsen TTH. Sensations do not usually include nausea but light sensitivity may be present. TTH may occur simultaneously with fibromyalgia and psychiatric disturbances.
3) Cluster Headache
Cluster headaches have a periodicity of some kind. Attacks may occur daily at or near the same time of day. Episodes can last for 15 minutes up to many hours if left untreated. The frequency can be up to 8 times per day with varying degrees of remission. The pain is often severe and located in one region of the head. This type of headache may be serious and require laboratory testing and imaging studies.
Secondary Headache Disorders
A headache may occur due to a primary medical condition, which may cause, precipitate, or trigger headaches:
- Head and/or neck trauma – These cervicogenic headaches may damage the skull and nerves in the neck. Often trauma from accidents, sports, or violence can trigger post-traumatic headache (PTH). Injury to the brain, head, and neck happens when acceleration and deceleration forces act to destabilize the system. Headache can develop immediately and up to seven days after a mild, moderate or severe event. Headaches can persist for months or years after a traumatic injury.
- Cranial or cervical vascular or non-vascular disorder – A high intensity headache called a thunderclap headache may appear suddenly. This rare form of headache may be due to a cerebral aneurysm. Other conditions include bleeding from cerebral AVM, cerebral venous sinus thrombosis, and pituitary apoplexy. Water on the brain, hydrocephalus, could be the culprit.
- A substance or its withdrawal – People can experience a headache or reaction when using pharmacologic agents prescribed for other conditions. Medication overuse (MOH) headaches occur when patients experience reactions with prescribed pharmacologic agents. Analgesics like nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates like codeine, butalbital, and oxycodone are used and negatively interact with medications designed to prevent headache. When the prescribed medication does not improve headache symptoms, physicians suspect MOH. Taking analgesics and opiates to help with pain in the short term, may lead to more frequent, intense and chronic headaches. Medication withdrawal may also lead to headache. Discontinuation of birth control pills, corticosteroids, SSRI’s, NSAIDs, antidepressants and other prescribed medications may trigger headaches.
- Infection – Intracranial, virus, fungal, bacterial or systemic infection can produce a headache of varying intensity and frequency due to inflammation in the spinal cord, brain, tissues, membranes and nerves.
- Ear, Nose and Throat – Disorders of the neck, eyes, ears, nose, sinuses, teeth, and mouth can cause headache. Sinusitis, otitis media, wisdom teeth, and temporomandibular joint syndrome (TMJ) can cause headache.
- Psychiatric disorder – Many people with headache also have psychological disturbances. The headache may come first, followed by complaints of depression, anxiety and panic. In others, the psychiatric problem may produce headaches.
In addition to the common subtype headaches and the secondary headaches, additional types of headaches may occur under certain circumstances, conditions, locations, activities and absence of normal circumstances:
- Weather – if the temperature rises and/or the barometric pressure drops, some people may experience a new or worsening headache.
- Hormonal – changes in the hormonal system like monthly menstruation may invite headache. Changes in estrogen levels and fluid retention may be responsible.
- Positional – certain bodily positions can cause headache. Workers who repeatedly perform certain tasks may have a risk of an ergonomics headache. Physical complaints such as back pain, neck and shoulder pain, and headache are common in workplaces. Anyone who spends time on screen based activities such as TV or the computer may be prone to headache.
- Dietary – some foods do not sit well for some individuals. Anecdotal evidence supports the avoidance of some foods for migraine sufferers. A food and headache diary may be useful to find culprit foods. Caffeine and monosodium glutamate are common triggers.
- Exertional – athletics, exercise, sex or even coughing or sneezing can trigger a mild or moderate headache in some individuals. The headache can begin immediately or after a long duration of the activity.
- Food poisoning – contaminants, toxins and viruses found in food may cause a headache along with nausea, diarrhea and vomiting.
- Alcohol – hangover headache happens after consuming too much alcohol. While certain amounts of alcohol may metabolize for some people, other people may require lesser amounts to stimulate a morning after headache. Those who are prone to hangover headache tend to drink less in future outings. Some people find that certain kinds of alcohol like wine can trigger a headache.
- High altitude – visiting a location at a high altitude like in the mountains can affect different people in varying ways. A headache and other symptoms may arise. People can drink more water, use supplemental oxygen, or move to a lower altitude to alleviate the headache.
- Sleep deprivation – can cause an increase in proteins that play a role in chronic pain. Those with sleep disorders are prone to migraines and those with migraines are susceptible to sleep disorders.
- Head banging – the up-down, the circular swing, the full body and the side-to-side head movements associated with rock, punk and metal music concerts may trigger headaches. Headache risk rises at tempos of 130 beats per minute. The range of motion in the head more than 75º can produce headache and dizziness.
Causes of Headaches
People are encouraged to tell their doctors about any family history of headaches in any variety, especially migraine headaches. Researchers have found that 56 percent of migraine patients have a family history of migraine. People who have migraine with aura are 96 percent likely to have a genetic susceptibility. Mutations in the CACNA1, ATP1A2 and SCN1A, and KCNK18 genes confer a probability of migraine headaches. The ATPIA gene is the most prevalent mutation.
Headache is a neuronal excitability disorder. The neurovascular system is more excitable in those with headaches. Nerve cells become overactive and spasm. Since headache is also associated with depression, serotonin depletion may also trigger headaches. Inflammation activates pain control systems. Nerve fibers activate, causing the throbbing and pulsing pain and sensitivity to touch.
Neuronal over activity invites the feeling preceding a migraine, the aura. This excitation ebbs and flows, causing the perception of lights, sounds and sensations. Some researchers suggest that all migraine sufferers and even common headache sufferers may have aura, without noticing it.
Those with migraines have physical differences in the somatosensory cortex area of the brain. This area is an average of 21 percent thicker in those with migraines, compared to those in the general population. This structural difference may cause migraines or the brain may change and thicken over time due to repeated migraine episodes. Dysfunction of sensory centers of the brain can also explain other pain disorders such as back pain or jaw pain.
- Low socioeconomic status – stress due to life conditions contributes to headache incidence. Poor diet, limited access to medical care, racial, sexual and gender discrimination plays a role in accumulated stress, headache and migraine. Those who have experienced the stress of childhood abuse have more headaches.
- Family History – 40-90 percent of headaches sufferers have a close family member, usually a parent or grandparent with headache disorder.
- Being a woman – women are more susceptible to headache with a 3:1 female to male ratio.
- Being young – younger people have a higher incidence of headaches.
- Being a smoker – a lifestyle choice to smoke cigarettes may cause vascular and nerve changes.
- Estrogen containing contraceptives – birth control methods can have the side effect of headache.
- Overweight – people who are overweight or obese have higher incidence of headaches. Those whose body fat distribution around the waist is greater tend to have migraine attacks. 37 percent of women with excess belly fat report migraines compared to 27 percent without excess belly fat.
Stigma Scale for Chronic Illness (SSCI) – 24-item questionnaire that quantifies life disruption for persons with neurological disorders.
Migraine Disability Scale (MIDAS) – measures the impact headaches have on daily life, by counting the headache days in the last 3 months.
SF-12 – a 12-question test for measuring the physical and mental components of life.
ID Migraine – screening test for headaches in the last 3 months with three questions. This instrument is a simple and easy to use test with a high degree of reliability.
Symptoms of headaches may or may not be a sign of other problems. Usual symptoms of headache may be intense pain, dizziness, pins and needles, sometimes blindness and cognitive difficulties. Blood pressure and heart rate can increase. Other signs and symptoms of headache can include:
- noxious stimuli – perfume and other smells
- visual and auditory disturbances – sensitivity to light or noise (photophobia and phonophobia)
- confusion or altered mental status
- musculoskeletal pain
- facial pain or sensitivity
- head trauma
- weakness or neurological deficits
- eye pain
- nasal congestion
- premenstrual, perimenopausal, contraceptive pill
- cigarette smoking
- pregnancy or postpartum
- other family members or pets sick
Medical Conditions that Cause Headaches
- angle-closure glaucoma
- brain abscess
- carbon monoxide poisoning and other toxins
- dental pain
- epidural hematoma
- giant cell arteritis
- hypoxia or hypercarbia
- mass lesion
- pre-eclampsia or eclampsia
- pseudotumor cerebri
- subarachnoid hemorrhage (SAH)
- subdural hematoma
- temporomandibular joint syndrome(TMJ)
- trigeminal myalgia
- venous sinus thrombosis
- viral syndrome
The patient’s medical history and physical examination usually determines the diagnosis. Primary care physicians usually see the majority of headaches cases. Some headache cases end up in the emergency room for lack of primary care insurance. Many headache patients see specialists like neurologists and pain management physicians. Patients see specialists when a diagnosis is difficult, multiple diagnoses are possible, when the patient is resistant to treatment, when the patient overuses other medications or when symptoms change. Five percent of headache cases require emergency room services and diagnostics.
A detailed medical history and a headache diary are extremely useful in diagnosing headaches. The history focuses on medical history, family history, precipitating factors and symptoms. Physicians should not use words or phrasing that the patient may perceive as negative. While many headache and migraine sufferers also have psychological problems, words like “depression” and “psychosomatic” are negative. Common questions can include:
- Is this the worst headache of their life?
- Is this a ‘typical’ headache?
- Does this kind of headache improve with over the counter medications?
- When did the headache begin?
- What are the exacerbating factors?
- Is it worse in the mornings or at a certain time of day?
Many patients with headaches may have few clues during the physical exam. In other words, the physical exam will be normal. Important measures during the exam are:
- Blood pressure
- Head, nose and throat
- Palpitations of head and neck
- Temporomandibular joint
- Dental examination
- Ear examination
- Neurological examination
- cranial nerve examination
- reflexes, facial sensation, and facial symmetry
- orientation and consciousness
- Ophthalmology examination to include
- pupillary symmetry and reactivity
- visual fields and ocular motility
- Symmetrical muscle tone and strength
International Classification of Headache Disorders-II (ICHD-II) divides migraine into six (6) subtypes and sub forms:
- 1.0 Migraine
- 1.1 Migraine without aura
- 1.2 Migraine with aura
- 1.2.1 Typical aura with migraine headache
- 1.2.2 Typical aura with non-migraine headache
- 1.2.3 Typical aura without headache
- 1.2.4 Familial hemiplegic migraine (FHM)
- 1.2.5 Sporadic hemiplegic migraine
- 1.2.6 Basilar-type migraine
- 1.3 Childhood periodic syndromes that are commonly precursors of migraine
- 1.3.1 Cyclical vomiting
- 1.3.2 Abdominal migraine
- 1.3.3 Benign paroxysmal vertigo of childhood
- 1.4 Retinal migraine
- 1.5 Complications of migraine
- 1.5.1 Chronic migraine
- 1.5.2 Status migrainosus
- 1.5.3 Persistent aura without infarction
- 1.5.4 Migrainous infarction
- 1.5.5 Migraine-triggered seizures
- 1.6 Probable migraine
- 1.6.1 Probable migraine without aura
- 1.6.2 Probable migraine with aura
- 1.6.5 Probable chronic migraine
- ESR – erythrocyte sedimentation rate.
- ABG – arterial blood gas test.
- Carboxyhaemoglobin – carbon monoxide exposure check.
- Pulse CO-oximeter – tests for elevated CO levels.
- FBC – full blood count.
- CSF culture – microscopy to identify infection.
- CT scans – cranial computed tomography identifies tumors and lesions.
- MRI – magnetic resonance imaging used when a neurologic examination identifies abnormalities.
- X-rays – imaging for cervical spine injury and fractures.
- Electromyogram and nerve conductionstudies – tests for neuropathies.
Headache often responds to analgesic medication, rest, and increased intake of water. Triggers and behaviors are analyzed and avoided. Prevention consists of drug use to reduce the frequency and/or duration of headaches, reduce pain and increase the quality of life. However, about one-third of patients do not respond to conservative treatments. For moderate and severe migraines, triptans, which target dilation of brain arteries, or dihydroergotamines, can reduce severity especially when taken early.
Daily doses of medication for prevention become a critical item for migraine patients to have on their person at all times. Medications can be problematic as almost all migraine drugs have some side effects. Some patients use over the counter medication that reduces the efficacy of prescribed drugs and invites more headaches. Some patients may abuse their prescriptions, or become addicted to opiates. Switching, re-trying, rotating, or combining drugs can adjust medications and provide more relief. Commonly prescribed medications include:
- NSAIDs or aspirin
- Paracetamol monotherapy
- Ergot alkaloids
- Butalbital-containing compounds
- Tricyclic antidepressants
- Calcium-channel blockers
- Calcitonin gene-related peptide (CGRP) inhibitors
- Angiotensin blockers
Headache patients often avoid exercise as it may worsen their symptoms. These patients lose the benefits of exercise, resulting in higher disease probability and less muscular tone, endurance and flexibility. Low impact exercise like cycling may provide some of the benefits of exercise without triggering headache. Reductions of weight through exercise may help reduce migraine incidence. Fat loss especially in the abdominal region may significantly reduce headaches.
Invasive surgical techniques may reduce headaches. The forehead is one site for surgical deactivation of migraine. This new therapy was found by accident, by a plastic surgeon. He noticed that patients who received plastic surgery or a cosmetic forehead lift, reported fewer headaches and migraines. When muscles are removed or remodeled, nerve pressure lessens and pain is reduced. Patients who had surgery report less frequent and severe headaches.
Deep Brain Stimulation (DBS) is the therapeutic use of electrical stimulation used for Parkinson’s disease, tremor, epilepsy, psychiatric illnesses, eating disorders and also headaches and migraines. Physical therapy, massage, chiropractic, acupuncture, trigger identification, biofeedback and patient education are valuable resources for headache patients. Keeping a headache diary is also an important tool.
Some oral medications work slowly and have side effects. New delivery methods can more effectively target signaling proteins in the brain. The class of drugs known as triptans blocks the signaling proteins from dilating arteries. The oral method of taking triptans is slow acting and may confer a risk for heart problems. Inhalable medications are safe, effective and reliable for many conditions including headache. Inhalable triptans could speed delivery of the drug into the neurovascular system and reduce headache duration and severity.
Botulinum toxin type A injected into trigger points on the head can reduce migraine frequency. The anterior temporal and the sub occipital regions and the glabellar, frontalis, and temporalis muscles have been injected with Botox, with success. Patients reported feeling much better. The Food and Drug Administration (USA) has recently approved Botulinum for the treatment of chronic migraine.
The instinct or tendency of migraine sufferers to find a quiet, dark and empty room is proven and scientifically helpful. Research shows that migraine sufferers, especially those with aura, have problems tuning out visual stimulation. This visual noise over stimulates the nervous system. Cluttered environments, televisions, computers, bright colors and patterns can trigger nerve cells and clusters into over activity. The nerve cells spasm and cause a headache. Migraine patients may be able to forestall headaches by paying special attention to their environment and visual noise.
Transcranial magnetic stimulation (TMS) is a new device and a new method for treating migraine, especially migraine aura patients. Patients with migraine aura found that the magnetic pulses from the device passed harmlessly through their brain. The magnetic energy also blocked the neuronal excitement causing their migraines. Blocking the abnormal brain waves allowed the patients to be pain-free at intervals of 2, 24 and 48 hours. Developers aim to make the device small and portable. Migraine patients will carry the device with them at all times. At the first sign of aura or pain, the user “zaps” the brain with magnetic pulses.
A device implanted with an invasive surgical procedure, may help patients who do not respond to conventional treatment or who cannot tolerate side effects from drugs. The device works by delivering electrical impulses to the occipital nerves. The device is a small rechargeable neurostimulator and approved by the FDA for spinal cord stimulation. The PRECISION™ Spinal Cord Stimulator (SCS) System is a neurostimulation device with a signal generator and a remote control. An insulated lead wire is implanted at the back of the neck. The wire conducts signals to the remote control. The patient or a health care provider directs the remote control to send impulses to the nerves when migraine symptoms develop.
Tinted glasses for the eyes, precision ophthalmic tints (POTs), may help reduce visual noise and limit intense patterns for migraine patients. The visual patterns most likely to irritate migraine patients have high contrast stripes, which an individual perceives as shape and movement. Migraine patients reported that they had half as many episodes when they wore the glasses.
Headaches are a universal condition, experienced by almost everyone. Re-occurring headaches and severe headaches, however, can cause major problems. Repeated bouts of throbbing pain can reduce individuals to low levels of functioning. Stronger acting medications like triptans can mimic serotonin in the brain. Complementary medicine with acupuncture, yoga, breathing, and medication has helped many migraine patients. Others have tried butterbur and CoQ10 as supplements. Headache patients should see a doctor, as headache is a sign of potentially harmful conditions.