Headache

Last updated
Headache
SynonymCephalalgia
Headache.png
Woman with a headache.
Specialty Neurology

Headache is the symptom of pain anywhere in the region of the head or neck. It occurs in migraines (sharp, or throbbing pains), tension-type headaches, and cluster headaches. [1] Frequent headaches can affect relationships and employment. [1] There is also an increased risk of depression in those with severe headaches. [1]

Pain type of unpleasant feeling

Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain's widely used definition defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"; however, due to it being a complex, subjective phenomenon, defining pain has been a challenge. In medical diagnosis, pain is regarded as a symptom of an underlying condition.

Head cephalic part of an animal

A head is the part of an organism which usually includes the ears, brain, forehead, cheeks, chin, eyes, nose, and mouth, each of which aid in various sensory functions such as sight, hearing, smell, and taste, respectively. Some very simple animals may not have a head, but many bilaterally symmetric forms do, regardless of size.

Neck part of the body, on many terrestrial or secondarily aquatic vertebrates, that distinguishes the head from the torso or trunk

The neck is the part of the body, on many vertebrates, that separates the head from the torso. It contains blood vessels and nerves that supply structures in the head to the body. These in humans include part of the esophagus, the larynx, trachea, and thyroid gland, major blood vessels including the carotid arteries and jugular veins, and the top part of the spinal cord.

Contents

Headaches can occur as a result of many conditions whether serious or not. There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society. Causes of headaches may include dehydration, fatigue, sleep deprivation, stress, the effects of medications, the effects of recreational drugs, viral infections, loud noises, common colds, head injury, rapid ingestion of a very cold food or beverage, and dental or sinus issues.

The International Headache Society (IHS) is a charity membership organisation founded in 1981 for those with a professional commitment to helping people affected by headache.

Treatment of a headache depends on the underlying cause, but commonly involves pain medication. A headache is one of the most commonly experienced of all physical discomforts.

Analgesic pharmaceutical drug

An analgesic or painkiller is any member of the group of drugs used to achieve analgesia, relief from pain.

About half of adults have a headache in a given year. [1] Tension headaches are the most common, affecting about 1.6 billion people (21.8% of the population) followed by migraine headaches which affect about 848 million (11.7%). [2]

Cause

There are more than 200 types of headaches. Some are harmless and some are life-threatening. The description of the headache and findings on neurological examination, determine whether additional tests are needed and what treatment is best. [3]

Neurological examination

A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical history, but not deeper investigation such as neuroimaging. It can be used both as a screening tool and as an investigative tool, the former of which when examining the patient when there is no expected neurological deficit and the latter of which when examining a patient where you do expect to find abnormalities. If a problem is found either in an investigative or screening process, then further tests can be carried out to focus on a particular aspect of the nervous system.

Primary vs. secondary headaches

Headaches are broadly classified as "primary" or "secondary". [4] Primary headaches are benign, recurrent headaches not caused by underlying disease or structural problems. For example, migraine is a type of primary headache. While primary headaches may cause significant daily pain and disability, they are not dangerous. Secondary headaches are caused by an underlying disease, like an infection, head injury, vascular disorders, brain bleed or tumors. Secondary headaches can be harmless or dangerous. Certain "red flags" or warning signs indicate a secondary headache may be dangerous. [5]

Migraine brain disease characterized by recurrent headaches on one side

A migraine is a primary headache disorder characterized by recurrent headaches that are moderate to severe. Typically, the headaches affect one half of the head, are pulsating in nature, and last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. The pain is generally made worse by physical activity. Up to one-third of people have an aura: typically a short period of visual disturbance that signals that the headache will soon occur. Occasionally, an aura can occur with little or no headache following it.

Head injury a very serious trauma to the cranium

A head injury is any injury that results in trauma to the skull or brain. The terms traumatic brain injury and head injury are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

Subarachnoid hemorrhage bleeding into the subarachnoid space

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever, and sometimes seizures. Neck stiffness or neck pain are also relatively common. In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed.

Primary headaches

90% of all headaches are primary headaches. Primary headaches usually first start when people are between 20 and 40 years old. [6] The most common types of primary headaches are migraines and tension-type headaches. [6] They have different characteristics. Migraines typically present with pulsing head pain, nausea, photophobia (sensitivity to light) and phonophobia (sensitivity to sound). Tension-type headaches usually present with non-pulsing "bandlike" pressure on both sides of the head, not accompanied by other symptoms. [7] Other very rare types of primary headaches include: [5]

Secondary headaches

Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication overuse headache may occur in those using excessive painkillers for headaches, paradoxically causing worsening headaches. [3]

More serious causes of secondary headaches include: [5]

Gastrointestinal disorders may cause headaches, including Helicobacter pylori infection, celiac disease, non-celiac gluten sensitivity, irritable bowel syndrome, inflammatory bowel disease, gastroparesis, and hepatobiliary disorders. [8] [9] [10] The treatment of the gastrointestinal disorders may lead to a remission or improvement of headaches. [10]

Pathophysiology

The brain itself is not sensitive to pain, because it lacks pain receptors. However, several areas of the head and neck do have pain receptors and can thus sense pain. These include the extracranial arteries, middle meningeal artery, large veins, venous sinuses, cranial and spinal nerves, head and neck muscles, the meninges, falx cerebri, parts of the brainstem, eyes, ears, teeth and lining of the mouth. [11] [12] Pial arteries, rather than pial veins are responsible for pain production. [5]

Headaches often result from traction to or irritation of the meninges and blood vessels. The nociceptors may be stimulated by head trauma or tumors and cause headaches. Blood vessel spasms, dilated blood vessels, inflammation or infection of meninges and muscular tension can also stimulate nociceptors and cause pain. [12] Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts.

Primary headaches are more difficult to understand than secondary headaches. The exact mechanisms which cause migraines, tension headaches and cluster headaches are not known. There have been different hypotheses over time which attempt to explain what happens in the brain to cause these headaches.

Migraines are currently thought to be caused by dysfunction of the nerves in the brain. [13] Previously, migraines were thought to be caused by a primary problem with the blood vessels in the brain. [14] This vascular theory, which was developed in the 20th century by Wolff, suggested that the aura in migraines is caused by constriction of intracranial vessels (vessels inside the brain), and the headache itself is caused by rebound dilation of extracranial vessels (vessels just outside the brain). Dilation of these extracranial blood vessels activates the pain receptors in the surrounding nerves, causing a headache. The vascular theory is no longer accepted. [13] [15] Studies have shown migraine head pain is not accompanied by extracranial vasodilation, but rather only has some mild intracranial vasodilation. [16]

Currently, most specialists think migraines are due to a primary problem with the nerves in the brain. [13] Auras are thought to be caused by a wave of increased activity of neurons in the cerebral cortex (a part of the brain) known as cortical spreading depression [17] followed by a period of depressed activity. [18] Some people think headaches are caused by the activation of sensory nerves which release peptides or serotonin, causing inflammation in arteries, dura and meninges and also cause some vasodilation. Triptans, medications which treat migraines, block serotonin receptors and constrict blood vessels. [19]

People who are more susceptible to experience migraines without headache are those who have a family history of migraines, women, and women who are experiencing hormonal changes or are taking birth control pills or are prescribed hormone replacement therapy. [20]

Tension headaches are thought to be caused by activation of peripheral nerves in the head and neck muscles [21]

Cluster headaches involve overactivation of the trigeminal nerve and hypothalamus in the brain, but the exact cause is unknown. [22]

Diagnostic approach

Differential diagnosis of headaches
Tension headache New daily persistent headache Cluster headache Migraine
mild to moderate dull or aching painsevere painmoderate to severe pain
duration of 30 minutes to several hoursduration of at least four hours dailyduration of 30 minutes to 3 hoursduration of 4 hours to 3 days
Occur in periods of 15 days a month for three monthsmay happen multiple times in a day for monthsperiodic occurrence; several per month to several per year
located as tightness or pressure across headlocated on one or both sides of headlocated one side of head focused at eye or temple located on one or both sides of head
consistent painpain describable as sharp or stabbingpulsating or throbbing pain
no nausea or vomitingnausea, perhaps with vomiting
no aura no auraauras
uncommonly, light sensitivity or noise sensitivitymay be accompanied by running nose, tears, and drooping eyelid, often only on one sidesensitivity to movement, light, and noise
exacerbated by regular use of acetaminophen or NSAIDS may exist with tension headache [23]

Most headaches can be diagnosed by the clinical history alone. [5] If the symptoms described by the person sound dangerous, further testing with neuroimaging or lumbar puncture may be necessary. Electroencephalography (EEG) is not useful for headache diagnosis. [24]

The first step to diagnosing a headache is to determine if the headache is old or new. [25] A "new headache" can be a headache that has started recently, or a chronic headache that has changed character. [25] For example, if a person has chronic weekly headaches with pressure on both sides of his head, and then develops a sudden severe throbbing headache on one side of his head, they have a new headache.

Red flags

It can be challenging to differentiate between low-risk, benign headaches and high-risk, dangerous headaches since symptoms are often similar. [26] Headaches that are possibly dangerous require further lab tests and imaging to diagnose.

The American College for Emergency Physicians published criteria for low-risk headaches. They are as follows: [27]

A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes which may be life-threatening or cause long-term damage. These "red flag" symptoms means that a headache warrants further investigation with neuroimaging and lab tests. [6]

In general, people complaining of their "first" or "worst" headache warrant imaging and further workup. [6] People with progressively worsening headache also warrant imaging, as they may have a mass or a bleed that is gradually growing, pressing on surrounding structures and causing worsening pain. [26] People with neurological findings on exam, such as weakness, also need further workup. [26]

The American Headache Society recommends using "SSNOOP", a mnemonic to remember the red flags for identifying a secondary headache: [25]

Other red flag symptoms include: [6] [25] [26] [28]

Red FlagPossible causesReason why red flag indicates possible causesDiagnostic tests
New headache after age 50Temporal arteritis, mass in brainTemporal arteritis is an inflammation of vessels close to the temples in older people, which decreases blood flow to the brain and causes pain. May also have tenderness in temples or jaw claudication. Some brain cancers are more common in older people.Erythrocyte sedimentation rate (diagnostic test for temporal arteritis), neuroimaging
Very sudden onset headache (thunderclap headache)Brain bleed (subarachnoid hemorrhage, hemorrhage into mass lesion, vascular malformation), pituitary apoplexy, mass (especially in posterior fossa)A bleed in the brain irritates the meninges which causes pain. Pituitary apoplexy (bleeding or impaired blood supply to the pituitary gland at the base of the brain) is often accompanied by double vision or visual field defects, since the pituitary gland is right next to the optic chiasm (eye nerves). Neuroimaging, lumbar puncture if computed tomography is negative
Headaches increasing in frequency and severityMass, subdural hematoma, medication overuseAs a brain mass gets larger, or a subdural hematoma (blood outside the vessels underneath the dura) it pushes more on surrounding structures causing pain. Medication overuse headaches worsen with more medication taken over time.Neuroimaging, drug screen
New onset headache in a person with possible HIV or cancer Meningitis (chronic or carcinomatous), brain abscess including toxoplasmosis, metastasis People with HIV or cancer are immunosuppressed so are likely to get infections of the meninges or infections in the brain causing abscesses. Cancer can metastasize, or travel through the blood or lymph to other sites in the body.Neuroimaging, lumbar puncture if neuroimaging is negative
Headache with signs of total body illness (fever, stiff neck, rash) Meningitis, encephalitis (inflammation of the brain tissue), Lyme disease, collagen vascular disease A stiff neck, or inability to flex the neck due to pain, indicates inflammation of the meninges. Other signs of systemic illness indicates infection.Neuroimaging, lumbar puncture, serology (diagnostic blood tests for infections)
Papilledema Brain mass, benign intracranial hypertension (pseudotumor cerebri), meningitis Increased intracranial pressure pushes on the eyes (from inside the brain) and causes papilledema.Neuroimaging, lumbar puncture
Severe headache following head traumaBrain bleeds (intracranial hemorrhage, subdural hematoma, epidural hematoma), post-traumatic headacheTrauma can cause bleeding in the brain or shake the nerves, causing a post-traumatic headacheNeuroimaging of brain, skull, and possibly cervical spine
Inability to move a limbArteriovenous malformation, collagen vascular disease, intracranial mass lesionFocal neurological signs indicate something is pushing against nerves in the brain responsible for one part of the bodyNeuroimaging, blood tests for collagen vascular diseases
Change in personality, consciousness, or mental status Central nervous system infection, intracranial bleed, massChange in mental status indicates a global infection or inflammation of the brain, or a large bleed compressing the brainstem where the consciousness centers lieBlood tests, lumbar puncture, neuroimaging
Headache triggered by cough, exertion or while engaged in sexual intercourseMass lesion, subarachnoid hemorrhageCoughing and exertion increases the intra cranial pressure, which may cause a vessel to burst, causing a subarachnoid hemorrhage. A mass lesion already increases intracranial pressure, so an additional increase in intracranial pressure from coughing etc. will cause pain.Neuroimaging, lumbar puncture

Old headaches

Old headaches are usually primary headaches and are not dangerous. They are most often caused by migraines or tension headaches. Migraines are often unilateral, pulsing headaches accompanied by nausea or vomiting. There may be an aura (visual symptoms, numbness or tingling) 30–60 minutes before the headache, warning the person of a headache. Migraines may also not have auras. [28] Tension type headaches usually have bilateral "bandlike" pressure on both sides of the head usually without nausea or vomiting. However, some symptoms from both headache groups may overlap. It is important to distinguish between the two because the treatments are different. [28]

The mnemonic 'POUND' helps distinguish between migraines and tension type headaches. POUND stands for Pulsatile quality, 4–72 hOurs in length, Unilateral location, Nausea or vomiting, Disabling intensity. [7] One review article found that if 4–5 of the POUND characteristics are present, migraine is 24 times as likely a diagnosis than tension type headache (likelihood ratio 24). If 3 characteristics of POUND are present, migraine is 3 times more likely a diagnosis than tension type headache (likelihood ratio 3). [7] If only 2 POUND characteristics are present, tension type headaches are 60% more likely (likelihood ratio 0.41). Another study found the following factors independently each increase the chance of migraine over tension type headache: nausea, photophobia, phonophobia, exacerbation by physical activity, unilateral, throbbing quality, chocolate as headache trigger, cheese as headache trigger. [29]

Cluster headaches are relatively rare (1 in 1000 people) and are more common in men than women. [30] They present with sudden onset explosive pain around one eye and are accompanied by autonomic symptoms (tearing, runny nose and red eye). [5]

Temporomandibular jaw pain (chronic pain in the jaw joint), and cervicogenic headache (headache caused by pain in muscles of the neck) are also possible diagnoses. [25]

For chronic, unexplained headaches, keeping a headache diary can be useful for tracking symptoms and identifying triggers, such as association with menstrual cycle, exercise and food. While mobile electronic diaries for smartphones are becoming increasingly common, a recent review found most are developed with a lack of evidence base and scientific expertise. [31]

New headaches

New headaches are more likely to be dangerous secondary headaches. They can, however, simply be the first presentation of a chronic headache syndrome, like migraine or tension-type headaches.

One recommended diagnostic approach is as follows. [32] If any urgent red flags are present such as visual loss, new seizures, new weakness, new confusion, further workup with imaging and possibly a lumbar puncture should be done (see red flags section for more details). If the headache is sudden onset (thunderclap headache), a computed tomography test to look for a brain bleed (subarachnoid hemorrhage) should be done. If the CT scan does not show a bleed, a lumbar puncture should be done to look for blood in the CSF, as the CT scan can be falsely negative and subarachnoid hemorrhages can be fatal. If there are signs of infection such as fever, rash, or stiff neck, a lumbar puncture to look for meningitis should be considered. If there is jaw claudication and scalp tenderness in an older person, a temporal artery biopsy to look for temporal arteritis should be performed and immediate treatment should be started.

Neuroimaging

Old headaches

The US Headache Consortium has guidelines for neuroimaging of non-acute headaches. [33] Most old, chronic headaches do not require neuroimaging. If a person has the characteristic symptoms of a migraine, neuroimaging is not needed as it is very unlikely the person has an intracranial abnormality. [34] If the person has neurological findings, such as weakness, on exam, neuroimaging may be considered.

New headaches

All people who present with red flags indicating a dangerous secondary headache should receive neuroimaging. [28] The best form of neuroimaging for these headaches is controversial. [6] Non-contrast computerized tomography (CT) scan is usually the first step in head imaging as it is readily available in Emergency Departments and hospitals and is cheaper than MRI. Non-contrast CT is best for identifying an acute head bleed. Magnetic Resonance Imaging (MRI) is best for brain tumors and problems in the posterior fossa, or back of the brain. [6] MRI is more sensitive for identifying intracranial problems, however it can pick up brain abnormalities that are not relevant to the person's headaches. [6]

The American College of Radiology recommends the following imaging tests for different specific situations: [35]

Clinical FeaturesRecommended neuroimaging test
Headache in immunocompromised people (cancer, HIV) MRI of head with or without contrast
Headache in people older than 60 with suspected temporal arteritisMRI of head with or without contrast
Headache with suspected meningitisCT or MRI without contrast
Severe headache in pregnancyCT or MRI without contrast
Severe unilateral headache caused by possible dissection of carotid or arterial arteriesMRI of head with or without contrast, Magnetic Resonance Angiography or Computed Tomography Angiography of head and neck.
Sudden onset headache or worst headache of lifeCT of head without contrast, Computed Tomography Angiography of head and neck with contrast, Magnetic Resonance Angiography of head and neck with and without contrast, MRI of head without contrast

Lumbar puncture

A lumbar puncture is a procedure in which cerebral spinal fluid is removed from the spine with a needle. A lumbar puncture is necessary to look for infection or blood in the spinal fluid. A lumbar puncture can also evaluate the pressure in the spinal column, which can be useful for people with idiopathic intracranial hypertension (usually young, obese women who have increased intracranial pressure), or other causes of increased intracranial pressure. In most cases, a CT scan should be done first. [5]

Classification

Headaches are most thoroughly classified by the International Headache Society's International Classification of Headache Disorders (ICHD), which published the second edition in 2004. [36] The third edition of the International Headache Classification was published in 2013 in a beta version ahead of the final version. [37] This classification is accepted by the WHO. [38]

Other classification systems exist. One of the first published attempts was in 1951. [39] The US National Institutes of Health developed a classification system in 1962. [40]

ICHD-2

The International Classification of Headache Disorders (ICHD) is an in-depth hierarchical classification of headaches published by the International Headache Society. It contains explicit (operational) diagnostic criteria for headache disorders. The first version of the classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in 2004. [41]

The classification uses numeric codes. The top, one-digit diagnostic level includes 14 headache groups. The first four of these are classified as primary headaches, groups 5-12 as secondary headaches, cranial neuralgia, central and primary facial pain and other headaches for the last two groups. [42]

The ICHD-2 classification defines migraines, tension-types headaches, cluster headache and other trigeminal autonomic headache as the main types of primary headaches. [36] Also, according to the same classification, stabbing headaches and headaches due to cough, exertion and sexual activity (sexual headache) are classified as primary headaches. The daily-persistent headaches along with the hypnic headache and thunderclap headaches are considered primary headaches as well.

Secondary headaches are classified based on their cause and not on their symptoms. [36] According to the ICHD-2 classification, the main types of secondary headaches include those that are due to head or neck trauma such as whiplash injury, intracranial hematoma, post craniotomy or other head or neck injury. Headaches caused by cranial or cervical vascular disorders such as ischemic stroke and transient ischemic attack, non-traumatic intracranial hemorrhage, vascular malformations or arteritis are also defined as secondary headaches. This type of headaches may also be caused by cerebral venous thrombosis or different intracranial vascular disorders. Other secondary headaches are those due to intracranial disorders that are not vascular such as low or high pressure of the cerebrospinal fluid pressure, non-infectious inflammatory disease, intracranial neoplasm, epileptic seizure or other types of disorders or diseases that are intracranial but that are not associated with the vasculature of the central nervous system. ICHD-2 classifies headaches that are caused by the ingestion of a certain substance or by its withdrawal as secondary headaches as well. This type of headache may result from the overuse of some medications or by exposure to some substances. HIV/AIDS, intracranial infections and systemic infections may also cause secondary headaches. The ICHD-2 system of classification includes the headaches associated with homeostasis disorders in the category of secondary headaches. This means that headaches caused by dialysis, high blood pressure, hypothyroidism, and cephalalgia and even fasting are considered secondary headaches. Secondary headaches, according to the same classification system, can also be due to the injury of any of the facial structures including teeth, jaws, or temporomandibular joint. Headaches caused by psychiatric disorders such as somatization or psychotic disorders are also classified as secondary headaches.

The ICHD-2 classification puts cranial neuralgias and other types of neuralgia in a different category. According to this system, there are 19 types of neuralgias and headaches due to different central causes of facial pain. Moreover, the ICHD-2 includes a category that contains all the headaches that cannot be classified.

Although the ICHD-2 is the most complete headache classification there is and it includes frequency in the diagnostic criteria of some types of headaches (primarily primary headaches), it does not specifically code frequency or severity which are left at the discretion of the examiner. [36]

NIH

The NIH classification consists of brief definitions of a limited number of headaches. [43]

The NIH system of classification is more succinct and only describes five categories of headaches. In this case, primary headaches are those that do not show organic or structural cause. According to this classification, headaches can only be vascular, myogenic, cervicogenic, traction and inflammatory.

Management

An old advertisement for a headache medicine. Image-Lottie Collins sings and dances to the tunes of Ta-Ra-Ra Boom-de-ay in a Bromo-Seltzer ad.jpg
An old advertisement for a headache medicine.

Primary headache syndromes have many different possible treatments. In those with chronic headaches the long term use of opioids appears to result in greater harm than benefit. [44]

Migraines

Migraine can be somewhat improved by lifestyle changes, but most people require medicines to control their symptoms. [5] Medications are either to prevent getting migraines, or to reduce symptoms once a migraine starts.

Preventive medications are generally recommended when people have more than four attacks of migraine per month, headaches last longer than 12 hours or the headaches are very disabling. [5] [45] Possible therapies include beta blockers, antidepressants, anticonvulsants and NSAIDs. [45] The type of preventive medicine is usually chosen based on the other symptoms the person has. For example, if the person also has depression, an antidepressant is a good choice.

Abortive therapies for migraines may be oral, if the migraine is mild to moderate, or may require stronger medicine given intravenously or intramuscularly. Mild to moderate headaches should first be treated with acetaminophen (paracetamol) or NSAIDs, like ibuprofen. If accompanied by nausea or vomiting, an antiemetic such as metoclopramide (Reglan) can be given orally or rectally. Moderate to severe attacks should be treated first with an oral triptan, a medication which mimics serotonin (an agonist) and causes mild vasoconstriction. If accompanied by nausea and vomiting, parenteral (through a needle in the skin) triptans and antiemetics can be given.

Several complementary and alternative strategies can help with migraines. The American Academy of Neurology guidelines for migraine treatment in 2000 stated relaxation training, electromyographic feedback and cognitive behavioral therapy may be considered for migraine treatment, along with medications. [46]

Tension-type headaches

Tension-type headaches can usually be managed with NSAIDs (ibuprofen, naproxen, aspirin), or acetaminophen. [5] Triptans are not helpful in tension-type headaches unless the person also has migraines. For chronic tension type headaches, amitriptyline is the only medication proven to help. [5] [47] [48] Amitriptyline is a medication which treats depression and also independently treats pain. It works by blocking the reuptake of serotonin and norepinephrine, and also reduces muscle tenderness by a separate mechanism. [47] Studies evaluating acupuncture for tension-type headaches have been mixed. [49] [50] [51] [52] [53] Overall, they show that acupuncture is probably not helpful for tension-type headaches.

Cluster headaches

Abortive therapy for cluster headaches includes subcutaneous sumatriptan (injected under the skin) and triptan nasal sprays. High flow oxygen therapy also helps with relief. [5]

For people with extended periods of cluster headaches, preventive therapy can be necessary. Verapamil is recommended as first line treatment. Lithium can also be useful. For people with shorter bouts, a short course of prednisone (10 days) can be helpful. Ergotamine is useful if given 1–2 hours before an attack. [5] See cluster headaches for more detailed information.

Secondary headaches

Treatment of secondary headaches involves treating the underlying cause. For example, a person with meningitis will require antibiotics. A person with a brain tumor may require surgery, chemotherapy or brain radiation.

Neuromodulation

Peripheral neuromodulation has tentative benefits in primary headaches including cluster headaches and chronic migraine. [54] How it may work is still being looked into. [54]

Epidemiology

Approximately 64–77% of people have a headache at some point in their lives. During each year, on average, 46–53% of people have headaches. [55] [56] Most of these headaches are not dangerous. Only approximately 1–5% of people who seek emergency treatment for headaches have a serious underlying cause. [57]

More than 90% of headaches are primary headaches. [58] Most of these primary headaches are tension headaches. [56] Most people with tension headaches have "episodic" tension headaches that come and go. Only 3.3% of adults have chronic tension headaches, with headaches for more than 15 days in a month. [56]

Approximately 12–18% of people in the world have migraines. [56] More women than men experience migraines. In Europe and North America, 5–9% of men experience migraines, while 12–25% of women experience migraines. [55]

Cluster headaches are very rare. They affect only 1–3 per thousand people in the world. Cluster headaches affect approximately three times as many men as women. [56]

History

An 1819 caricature by George Cruikshank depicting a headache. Cruikshank - The Head Ache.png
An 1819 caricature by George Cruikshank depicting a headache.

The first recorded classification system was published by Aretaeus of Cappadocia, a medical scholar of Greco-Roman antiquity. He made a distinction between three different types of headache: i) cephalalgia, by which he indicates a shortlasting, mild headache; ii) cephalea, referring to a chronic type of headache; and iii) heterocrania, a paroxysmal headache on one side of the head. Another classification system that resembles the modern ones was published by Thomas Willis, in De Cephalalgia in 1672. In 1787 Christian Baur generally divided headaches into idiopathic (primary headaches) and symptomatic (secondary ones), and defined 84 categories. [43]

Children

In general, children suffer from the same types of headaches as adults do, but their symptoms may be slightly different. The diagnostic approach to headache in children is similar to that of adults. However, young children may not be able to verbalize pain well. [59] If a young child is fussy, they may have a headache. [60]

Approximately 1% of emergency department visits for children are for headache. [61] [62] Most of these headaches are not dangerous. The most common type of headache seen in pediatric emergency rooms is headache caused by a cold (28.5%). Other headaches diagnosed in the emergency department include post-traumatic headache (20%), headache related to a problem with a ventriculoperitoneal shunt (a device put into the brain to remove excess CSF and reduce pressure in the brain) (11.5%) and migraine (8.5%). [62] [63] The most common serious headaches found in children include brain bleeds (subdural hematoma, epidural hematoma), brain abscesses, meningitis and ventriculoperitoneal shunt malfunction. Only 4–6.9% of kids with a headache have a serious cause. [60]

Just as in adults, most headaches are benign, but when head pain is accompanied with other symptoms such as speech problems, muscle weakness, and loss of vision, a more serious underlying cause may exist: hydrocephalus, meningitis, encephalitis, abscess, hemorrhage, tumor, blood clots, or head trauma. In these cases, the headache evaluation may include CT scan or MRI in order to look for possible structural disorders of the central nervous system. [64] If a child with a recurrent headache has a normal physical exam, neuroimaging is not recommended. Guidelines state children with abnormal neurologic exams, confusion, seizures and recent onset of worst headache of life, change in headache type or anything suggesting neurologic problems should receive neuroimaging. [60]

When children complain of headaches, many parents are concerned about a brain tumor. Generally, headaches caused by brain masses are incapacitating and accompanied by vomiting. [60] One study found characteristics associated with brain tumor in children are: headache for greater than 6 months, headache related to sleep, vomiting, confusion, no visual symptoms, no family history of migraine and abnormal neurologic exam. [65]

Some measures can help prevent headaches in children. Drinking plenty of water throughout the day, avoiding caffeine, getting enough and regular sleep, eating balanced meals at the proper times, and reducing stress and excess of activities may prevent headaches. [66] Treatments for children are similar to those for adults, however certain medications such as narcotics should not be given to children. [60]

Children who have headaches will not necessarily have headaches as adults. In one study of 100 children with headache, eight years later 44% of those with tension headache and 28% of those with migraines were headache free. [67] In another study of people with chronic daily headache, 75% did not have chronic daily headaches two years later, and 88% did not have chronic daily headaches eight years later. [68]

Related Research Articles

Cluster headache

Cluster headache (CH) is a neurological disorder characterized by recurrent severe headaches on one side of the head, typically around the eye. There is often accompanying eye watering, nasal congestion, or swelling around the eye on the affected side. These symptoms typically last 15 minutes to 3 hours. Attacks often occur in clusters which typically last for weeks or months and occasionally more than a year.

Tension headache

Tension headache, also known as tension-type headache (TTH), is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.

Medication overuse headache (MOH), also known as rebound headache usually occurs when analgesics are taken frequently to relieve headaches. Rebound headaches frequently occur daily, can be very painful and are a common cause of chronic daily headache. They typically occur in patients with an underlying headache disorder such as migraine or tension-type headache that "transforms" over time from an episodic condition to chronic daily headache due to excessive intake of acute headache relief medications. MOH is a serious, disabling and well-characterized disorder, which represents a worldwide problem and is now considered the third-most prevalent type of headache. Population-based studies report the prevalence rate of MOH to be 1% to 2% in the general population, but its relative frequency is much higher in secondary and tertiary care.

Visual snow visual impairment

Visual snow, also known as visual static, is a proposed condition in which people see white or black dots in parts or the whole of their visual fields. The problem is typically always present and can last years.

Triptan class of pharmaceutical drugs

Triptans are a family of tryptamine-based drugs used as abortive medication in the treatment of migraines and cluster headaches. This drug class was first introduced in the 1990s. While effective at treating individual headaches, they do not provide preventive treatment and are not considered a cure. They are not effective for the treatment of tension–type headache, except in persons who also experience migraines. They may be effective in disabling tension–type headaches, which exist on a spectrum of migraine. Triptans do not relieve other kinds of pain.

Sexual headaches are a type of headache that occur in the skull and neck during sexual activity, including masturbation or orgasm. These headaches are usually benign, but occasionally are caused by intracranial hemorrhage and cerebral infarction, especially if the pain is sudden and severe. They may be caused by general exertion, sexual excitement, or contraction of the neck and facial muscles. Most cases can be successfully treated with medication.

Post-concussion syndrome, also known as postconcussive syndrome or PCS, is a set of symptoms that may continue for weeks, months, or a year or more after a concussion – a mild form of traumatic brain injury (TBI). The rates of PCS vary, but most studies report that about 15% of individuals with a history of a single concussion develop persistent symptoms associated with the injury. A diagnosis may be made when symptoms resulting from concussion last for more than three months after the injury. Loss of consciousness is not required for a diagnosis of concussion or post-concussion syndrome.

Hemicrania continua (HC) is a persistent unilateral headache that responds to indomethacin. It is usually unremitting, but rare cases of remission have been documented. Hemicrania continua is considered a primary headache disorder, meaning that it is not caused by another condition.

Mixed tension migraines are also known as mixed migraines or mixed headaches. They combine characteristics of tension headaches and migraines.

Hypnic headaches are benign primary headaches that affect the elderly, with the average age of onset being 63 ± 11 years. They are moderate, throbbing, bilateral or unilateral headaches that wake the sufferer from sleep once or multiple times a night. They typically begin a few hours after sleep begins and can last from 15–180 min. There is normally no nausea, photophobia, phonophobia or autonomic symptoms associated with the headache. They commonly occur at the same time every night possibly linking the headaches with circadian rhythm, but polysomnography has recently revealed that the onset of hypnic headaches may be associated with REM sleep. Lithium carbonate 200–600 mg at bedtime is an effective treatment for most patients but for those that can not tolerate Lithium, Verapamil, indomethacin, melatonin or methysergide may be tried. Two patients have also responded to flunarizine 5 mg. It has also been shown that 1–2 cups of coffee or 100–200 mg of caffeine before bed can prevent hypnic headaches.

Neurological disorder disease of anatomical entity that is located in the central nervous system or located in the peripheral nervous system

A neurological disorder is any disorder of the nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord or other nerves can result in a range of symptoms. Examples of symptoms include paralysis, muscle weakness, poor coordination, loss of sensation, seizures, confusion, pain and altered levels of consciousness. There are many recognized neurological disorders, some relatively common, but many rare. They may be assessed by neurological examination, and studied and treated within the specialities of neurology and clinical neuropsychology.

Spontaneous cerebrospinal fluid leak

A spontaneous cerebrospinal fluid leak (SCSFL) is a medical condition in which the cerebrospinal fluid (CSF) surrounding the human brain and spinal cord leaks out of the surrounding protective dural sac for no apparent reason. The dura, a tough, inflexible tissue, is the outermost of the three layers of the meninges, the system of membranes surrounding the brain and spinal cord.

Orthostatic headache

Orthostatic headache is a medical condition in which a person develops a headache while vertical and the headache is relieved when horizontal. Previously it was often misdiagnosed as different primary headache disorders such as migraine or tension headaches. Increasing awareness of the symptom and its causes has prevented delayed or missed diagnosis.

New daily persistent headache (NDPH) is a primary headache syndrome which can mimic chronic migraine and chronic tension-type headache. The headache is daily and unremitting from very soon after onset, usually in a person who does not have a history of a primary headache disorder. The pain can be intermittent, but lasts more than 3 months. Headache onset is abrupt and people often remember the date, circumstance and, occasionally, the time of headache onset. One retrospective study stated that over 80% of patients could state the exact date their headache began.

The International Classification of Headache Disorders (ICHD) is a detailed hierarchical classification of all headache-related disorders published by the International Headache Society. It is considered the official classification of headaches by the World Health Organization, and, in 1992, was incorporated into the 10th edition of their International Classification of Diseases (ICD-10). Each class of headache contains explicit diagnostic criteria—meaning that the criteria include quantities rather than vague terms like several or usually—that are based on clinical and laboratory observations.

The NIH classification of headaches consists of brief, relatively vague glossary-type definitions of a limited number of headaches.

The classification of all headaches, including migraines, is organized by the International Headache Society, and published in the International Classification of Headache Disorders (ICHD). The current version, the ICHD-3 beta, was published in 2013.

Computed tomography of the head

Computed tomography (CT) scanning of the head uses a series of x-rays of the head taken from many different directions; the resulting data is transformed into a series of cross sections of the brain using a computer program. CT images of the head are used to investigate and diagnose brain injuries and other neurological conditions, as well as other conditions involving the skull or sinuses.; it used to guide some brain surgery procedures as well. CT scans expose the person getting them to ionizing radiation which has a risk of eventually causing cancer; some people have allergic reactions to contrast agents that are used in some CT procedures.

Migraine treatment may be either prophylactic (preventive) or abortive (rescue). Prevention is better than cure, so the ideal treatment goal is to prevent migraine attacks. Because migraine is an exceedingly complex condition, there are various preventive treatments which have their effect by disrupting different links in the chain of events that occur during a migraine attack. As rescue treatments also target and disrupt different processes occurring during migraine, these are summarized, with their relative merits and demerits.

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