- Interview Transcript
- Tension headaches
- Medication and painkiller headaches
- Hormone headaches
- Other causes of headaches
- Could it be something serious?
- Headache Pain
- CASE 2 DIAGNOSIS: HEMICRANIA CONTINUA
- What is causing this headache?
- Malfunction is the trigger
- One-sided pain
- The Facts
- Symptoms and Complications
- Making the Diagnosis
- Treatment and Prevention
Announcer: Questions every woman wonders about her health, body, and mind. This is, “Am I Normal?” on The Scope.
Interviewer: We’re talking with Dr. Kirtly Parker Jones, she’s the expert on all things women. Dr. Jones, is it common for women to come into your office and ask the question, “I’ve a headache. Is it normal?” That’s a normal question, right?
Dr. Jones: It’s a pretty common question. So first of all, in someone’s lifetime, pretty much everybody’s going to have a headache. Trying to find out what type of headache they are, how to predict them and how to treat them is something everybody should know. So let’s talk about this headache.
Interviewer: Yeah, so let’s play a little game here then.
Dr. Jones: Let’s play a little game.
Interviewer: Let’s play like detective here.
Dr. Jones: Yeah, okay.
Interviewer: So I’m going to use myself as the guinea pig. I’m just going to make things up because, you know . . .
Dr. Jones: Okay, stop, stop, stop. No, if I let you talk about your headache, talking to women about their headaches tells me the story of their life, and their kids, and oh by the way, their son’s getting married, and I can see already tension building up so this could be stressful. But if I get to talk and I want patients to have a two minutes of talking about their headaches, but then I want to ask questions. So . . .
Interviewer: Okay, yeah. Give me questions then.
Dr. Jones: You’re going to get your two minutes. I’m going to ask you.
Interviewer: Okay, okay. So we’re going to switch this around then.
Dr. Jones: Right, so . . .
Interviewer: Okay. All right.
Dr. Jones: First of all, how often do you have your headaches?
Interviewer: Every week.
Dr. Jones: Every week. About once a week?
Interviewer: Yeah, more or less.
Dr. Jones: Okay, once a week.
Interviewer: Once, twice a week.
Dr. Jones: Okay. Once or twice a week. So when you get to more than twice a week, it’s almost called chronic headache, but once or twice a week is very common. People have it more than twice a week. That’s only about 5% of people, but a lot of people have headache. About 80% of people will have a headache called tension headache, and for women, about 17% to 20% of women will have migraine. Now, women often think because the headache is bad it must be migraine because migraine headaches are . . .
Interviewer: It sounds bad.
Dr. Jones: . . . notorious. Yes, got this name migraine. There’s the whole cultural thing around migraine, but what you have may not be a migraine headache. So can you describe your headache to me? Where is it?
Dr. Jones: Okay, one side.
Interviewer: . . . but it’s throbbing. It’s just kind of . . .
Dr. Jones: One side throbbing. So that gives me two important cues that it’s probably a migraine type of headache. It’s one sided and it’s throbbing. Now, do anything bother you? When you have this headache do anything, sorts of things bother you?
Interviewer: Let’s say for the sake of this, let’s say no.
Dr. Jones: No. So many people with migraine, but not everyone would say, “The lights are too bright,” so they’re photophobic. They really don’t like lights and they’ll go into a dark room and it feels better when they don’t have bright light, but not everyone. Some people get nauseated and throw up. And some people actually have some symptoms around their jaw or their neck that feels like part of their neck or jaw feels funny or is tight. Now, can you tell when your headache is coming? Do you see any sparkles, or do you see anything before your headache starts?
Interviewer: Let’s say that I feel it coming.
Dr. Jones: You feel it coming?
Dr. Jones: You’ve got some twinkles in your eyes?
Dr. Jones: So it turns out that about 15% of people have migraine, and I think you have migraine, have what we call classic migraine. And classic migraine is usually marked by an aura. An aura is a visual sign that something’s going to happen, and it’s often one side of your visual field. You can see either jagged lines or twinkly lines that start small and then grow a little bit bigger and then get smaller. And the aura often precedes the headache, so that’s classic migraine.
So it’s unilateral, one-sided, throbbing often, sometimes with nausea and photophobia. And for about 15% of people with classic migraine they have aura, a visual disturbance. And the headache usually lasts anywhere for a couple of hours to a day, not longer than a day, usually. How long does yours last?
Interviewer: That sounds painful.
Dr. Jones: How long does yours last?
Interviewer: Let’s say half a day. Let’s go . . .
Dr. Jones: Half a day?
Interviewer: Let’s say half a day.
Dr. Jones: And how much does this bother you? How much does this get in your way?
Interviewer: When it happens, I don’t want to do anything else but just lay in my bed and hope it goes away.
Dr. Jones: Okay. Have you taken anything for it?
Interviewer: Advil, Tylenol.
Dr. Jones: And does it help a little?
Interviewer: . Let’s say yes.
Dr. Jones: Okay. So there’s no . . .
Interviewer: Or let’s say I would like to think it does.
Dr. Jones: Okay. Well, because any . . . If it’s going to last for half a day, then anything is eventually going to work because it’s going to go away.
Interviewer: You like to think it helps.
Dr. Jones: What you want is something that’s make it go away right now.
Dr. Jones: So in terms of treatment of migraine, it’s certainly some people do well. Some Tylenol or ibuprofen can help some. There are a new category of drugs, new meaning for the last 15 plus years or even longer called Triptans, and these actually, if you take them as soon as that little twinkly eye thing is going on, or soon as you think it’s coming . . .
Interviewer: The aura’s coming?
Dr. Jones: If you take them, they can decrease or block the headache part. So they have been very, very successful in treating migraine. If you take at the beginning . . . So if you’re having headache a couple times a week and it’s like this, and you have you to . . .
Interviewer: Like I know it’s coming.
Dr. Jones: . . . go to a doctor, right. You have to go to a doctor to get this prescription, you need to carry it with you in every purse you’ve got because if you have to run home, or drive home especially if you’re not feeling all that well, which isn’t that great, to go get it so you have to carry it with you.
Interviewer: Let’s back up a little bit and let’s talk just briefly about if there are no signs or symptoms. Like we talked about, “Yeah, I can see it, I can feel it coming.” What about the ones that are just sudden?
Dr. Jones: For people who don’t have an aura, the Triptans still work very well. It can shorten the course, the intensity, and duration of that migraine. So as soon as you start feeling the headache, that unilateral throbbing, happens a couple times a week, then taking it as soon as you begin to feel it will also shorten the course. So people with aura just have a little bit more warning before the headache starts.
Interviewer: So this is normal? So like once, twice a week for about half a day a day, that’s normal?
Dr. Jones: Well, normal. About 17% of women plus are going to have migraine in their lifetime.
Interviewer: Do you know why? What’s causing this?
Dr. Jones: We don’t know exactly why. We used to think, in the old days, that it was vasospasm that for some reason in the brain, the blood vessels would go become tight and then they would expand and that would hurt when they got expanded. That no longer is really the understanding that we have. So we’re not exactly sure. The mechanisms are difficult, but Triptans seem to work pretty well. When you have a headache ibuprofen can work.
What you really want to stay away from is taking ibuprofen all the time, or taking narcotics for these headaches because people can develop rebound headache. So rebound headache is when you get a headache after the stuff you’ve been taking for the headache stops, and then you get a more headache. So the goal is to try to take something . . .
Now, I asked what your triggers were. Triggers are things that you say, I think that I am . . . This is happening when I have my headache.”
Interviewer: I mean, I can’t think of any triggers, but . . .
Dr. Jones: Okay. Well, let me tell you some of the triggers.
Interviewer: Let’s be fun here and let’s have you tell me some triggers.
Dr. Jones: I’m going to tell you some triggers. So it turns out that there are some well-known triggers, and one is they fall into categories of change in habit. So if you usually sleeps X number of hours a night, or you usually get up at a certain time and now you’re changing that, you’re not getting . . .
Interviewer: Change your behavior.
Dr. Jones: Your behavior. So you have changed your behavior and you’re getting more sleep, you’re getting up later than you normally do, morning migraine is common. So you’re getting up too late or you’re getting up at a time that you aren’t used to those. So not enough sleep or a change in sleep habit, not enough food or a change in food habit, a weekend headache, vacation headache. So you’re stressed, stressed, stressed, stressed and all of a sudden you’re letting down and you’re sleeping more or you’re eating differently, so vacation headaches or change.
Interviewer: There’s such a thing as vacation headaches?
Dr. Jones: Yeah.
Interviewer: There is the headache that’s caused by vacation?
Dr. Jones: Yeah.
Dr. Jones: So you’re changing. So migraine is often associated when you’ve changed a habit. Caffeine withdrawal has its own kind of headache, but people drink much more coffee than they used to or less can trigger their migraine, although it can trigger different kinds of headaches too.
Interviewer: So that reminds me of what I like to call the hangover headache.
Dr. Jones: Well, so that’s a hangover. If you’re drinking, now so let’s talk about what you’re doing the night before twice a week. Twice a week you’ll go out with the girls or the boys or whoever you’re going out with and you drink way too much. So hangover headache is not a migraine. It is associated, we believe, with dehydration. So it turns out that when you drink a lot, you tend to pee a lot more and you get a little dehydrated.
So people say, “Well, before you go to bed, if you drank too much, you should drink a horde of water and take two aspirin.” Another it’s get yourself tanked up and then take some aspirin before you go to bed. So in general, I’d say that if these two headaches a week are preceded by a night time of drinking too much, then even if it is migraine, you’re drinking too much. So hangover headache. So there you go. That’s hangover headache.
Now, there’s another kind of headache which it doesn’t sound like you have, but 80% of people have this headache, and it’s called tension headache. Now, when you say the word “tension headache,” it makes you think that you’re tense. But in fact, what’s tense are the muscles around your scalp. So you have a thin layer of muscles all around your scalp and your forehead, in the back of your head, and across the top of your head. These headaches are bilateral. When people explain it to me they often cup their hands over the front of their head or the back of their head. These are very well treated with ibuprofen and drugs like that and sometimes Botox treatment.
Dr. Jones: It’s like Botox has been used for migraine as well, but Botox treatment for tension headaches. Remember, it’s not that you’re tense, but it’s because your muscles are tense.
Interviewer: Muscles are tense therefore Botox. It makes sense.
Dr. Jones: So that works as well. Now, I want to talk at the end that these are headaches that you are living with, but you’re not happy to live with. So they’re normal, but you’re not happy to have. There is the person who’s having, “Oh, this is the worst headache of my life.” And particularly for women, there are some headaches which are a signal for a devastating problem.
So these are people who might have a bleeding in their brain from an arteriovenous malformation, something called an AVM, a little blood venous area that starts to bleed in their brain. They could have a clot in their brain. They could be having a stroke. So these are various serious headaches. If this is the worst headache of your life and you are writhing, then you need to go to the ER.
Interviewer: How do you tell? Like, how can you tell if . . . because I feel like once a headache hits it’s always going to be the worst headache of your life because it’s just . . . it hurts.
Dr. Jones: Of course, but if you’re having it . . .
Interviewer: How do you tell?
Dr. Jones: . . . once a month or once a week you could say, “This is the worst headache of my life,” but it’s just like the headache I had last week or the following week.
Interviewer: You can live through it.
Interviewer: So there’s a lot more serious signs and symptoms that go along with it?
Dr. Jones: Right. So if it’s the worst headache of your life . . .
Interviewer: To the ER.
Dr. Jones: . . . and you haven’t had a headache, well then it’s a visit to the ER. So a bad headache, not all headaches are migraine, but migraines are common. Eighty percent of headaches are tension. They have to do with the muscles around the head, work well with ibuprofen, and some changes in behaviors that might actually . . . Eat well, sleep well, do your exercise about the same way. Migraine has treatment for the headache in Triptans. And then try to avoid your triggers. If you have headache, if it’s normal more than twice a week, it’s not normal.
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More than 10 million people in the UK get headaches regularly, making them one of the most common health complaints. But most aren’t serious and are easily treated.
In many cases, you can treat your headaches at home with over-the-counter painkillers and lifestyle changes, such as getting more rest and drinking enough fluids.
However, it’s a good idea to see your GP if your headaches aren’t relieved by over-the-counter treatments, or if they’re so painful or frequent that they affect your daily activities or are causing you to miss work.
Tension headaches are the most common type of headache and are what we think of as normal, “everyday” headaches. They feel like a constant ache that affects both sides of the head, as though a tight band is stretched around it.
A tension headache normally won’t be severe enough to prevent you doing everyday activities. They usually last for 30 minutes to several hours, but can last for several days.
The exact cause is unclear, but tension headaches have been linked to things such as stress, poor posture, skipping meals and dehydration.
Tension headaches can usually be treated with ordinary painkillers such as paracetamol and ibuprofen. Lifestyle changes, such as getting regular sleep, reducing stress and staying well hydrated, may also help. If a headache is getting persistently worse despite taking painkillers then make an appointment to speak to your GP.
Migraines are less common than tension headaches. They’re usually felt as a severe, throbbing pain at the front or side of the head. Some people also have other symptoms, such as nausea, vomiting and increased sensitivity to light or sound.
Migraines tend to be more severe than tension headaches and can stop you carrying out your normal daily activities. They usually last at least a couple of hours, and some people find they need to stay in bed for days at a time.
Most people can treat their migraines successfully with over-the-counter medication. But if they’re severe, you may need stronger medication that’s only available on prescription. This may be able to relieve and prevent your migraines.
Read more about migraines
Cluster headaches are a rare type of headache that occur in clusters for a month or two at a time around the same time of year.
They’re excruciatingly painful, causing intense pain around one eye, and often occur with other symptoms, such as a watering or red eye and a blocked or runny nose.
Pharmacy medications don’t ease the symptoms of a cluster headache, but a doctor can prescribe specific treatments to ease the pain and help prevent further attacks.
Medication and painkiller headaches
Some headaches are a side effect of taking a particular medication. Frequent headaches can also be caused by taking too many painkillers. This is known as a painkiller or medication-overuse headache.
A medication-overuse headache will usually get better within a few weeks once you stop taking the painkillers that are causing it, although your pain may get worse for a few days before it starts to improve.
Headaches in women are often caused by hormones, and many women notice a link with their periods. The combined contraceptive pill, the menopause and pregnancy are also potential triggers.
Reducing your stress levels, having a regular sleeping pattern, and ensuring you don’t miss meals may help reduce headaches associated with your menstrual cycle.
Other causes of headaches
Headaches can also have a number of other causes, including:
- drinking too much alcohol
- a head injury or concussion
- a cold or flu
- temporomandibular disorders – problems affecting the “chewing” muscles and the joints between the lower jaw and the base of the skull
- sinusitis – inflammation of the lining of the sinuses
- carbon monoxide poisoning
- sleep apnoea – a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing
Could it be something serious?
In the vast majority of cases, a headache isn’t a sign of a serious problem. But, rarely, it can be a symptom of a condition such as a stroke, meningitis, or a brain tumour.
A headache is more likely to be serious if:
- it occurs suddenly and is very severe – often described as a blinding pain unlike anything experienced before
- it doesn’t go away and gets worse over time
- it occurs after a severe head injury
- it’s triggered suddenly by coughing, laughing, sneezing, changes in posture, or physical exertion
- you have symptoms suggesting a problem with your brain or nervous system, including weakness, slurred speech, confusion, memory loss, and drowsiness
- you have additional symptoms, such as a high temperature (fever), a stiff neck, a rash, jaw pain while chewing, vision problems, a sore scalp, or severe pain and redness in one of your eyes
If you’re concerned that your headache might be serious, you should seek immediate medical advice. Contact your GP or the NHS 24 111 service as soon as possible, or go to your nearest accident and emergency (A&E) department.
Almost everyone gets a headache from time to time. There are 2 main types of headaches, and both types are common in people with cancer:
Primary headaches. These include migraines, cluster headaches, and tension headaches. Tension headaches are also called muscle contraction headaches.
Secondary headaches. These are from other medical conditions or underlying factors. These may be caused by a brain tumor, head injury, infection, or medicines.
Managing side effects, which can include headaches, is an important part of cancer care and treatment. This is called palliative care or supportive care. Talk with your health care team about any symptoms you or the person you are caring for experience.
Headaches may have different symptoms. These factors help describe them:
Timing. This is the time of day when you develop a headache. Sometimes, the timing of a headache provides a clue to its cause. For example, headaches later in the day are often tension headaches.
Frequency. This is how often you have a headache. For example, occasionally, weekly, or daily.
Triggers. These are the factors that start a headache. Triggers can include exposure to cold, blinking lights, loud noises, or specific foods.
Duration. This is how long the headache lasts. It may range from minutes to hours to days. Some headaches start and end very suddenly. Others come and go over several hours or days.
Location. This is the place where the pain occurs. For example, pain may develop in these places:
Over the eyes
In the forehead or temples
At the back of the neck
On one side of the head
Severity. This is the level of pain. It may range from mild to severe and incapacitating. Incapacitating means that you have difficulty moving or speaking during the headache. Some headaches start with mild pain that gradually becomes severe. Other times, they start with severe pain and remain that way.
Quality. This is the type of pain you experience. You may describe it with words such as:
Stabbing or piercing
A feeling of pressure
A dull ache
In addition to the headache itself, you may experience symptoms related to the headache, including:
Nausea and vomiting
Sensitivity to light or noise
Difficulty moving or speaking
Pain that increases with activity
Consider keeping a headache diary to track these symptoms. This will help your doctor diagnose and treat your headaches.
Causes of headaches
The following factors can cause a headache:
Cancer. Certain cancers may cause a headache, particularly these types:
Cancers of the brain and spinal cord
Pituitary gland tumors
Cancer of the upper throat, called nasopharyngeal cancer
Some forms of lymphoma
Cancer that has spread to the brain
Infections. Sinusitis and meningitis can cause headaches. Sinusitis is an infection of the sinuses. These are hollow passages in the bones around the nose. With meningitis, the protective membranes covering the brain and spinal cord swell.
Cancer treatment. The following cancer treatments can cause headaches:
Some types of chemotherapy, such as fluorouracil (5-FU, Adrucil) and procarbazine (Matulane)
Radiation therapy to the brain
Immunotherapy, a treatment that boosts the body’s natural defenses to fight cancer
Other medicine. Medicine for cancer-related symptoms or other conditions can cause headaches:
Antibiotics, used to treat infections
Antiemetics, used to prevent or treat vomiting
Cancer-related side effects or other conditions. Symptoms or side effects related to cancer or cancer treatment can also cause headaches:
Anemia, a low red blood count
Hypercalcemia, a high level of calcium
Thrombocytopenia, a low platelet count
Dehydration, a loss of too much water from the body. This may be caused by severe vomiting or diarrhea.
Other factors. Stress, fatigue, anxiety, and sleeping problems may also cause headaches.
Your health care team will assess your symptoms and medical history. They will also conduct a physical exam. This information will help determine the headache type and cause.
Tell the health care team if you have headaches with these features:
They are frequent or severe.
They wake you at night.
They have new patterns or a change in frequency.
They are new or exhibit new symptoms.
Your doctor may also order tests to help diagnose the cause of your headaches:
A computerized tomography (CT) scan. This makes a 3-dimensional picture of the inside of the body.
Magnetic resonance imaging (MRI) of the brain. This uses magnetic fields to produce detailed images of the body.
Other tests, based on the headache pattern and symptoms
Treating and managing headaches
When possible, doctors treat the condition that causes the headache. This can be done using medication or other strategies.
These medications may prevent and treat headaches or reduce the pain:
Over-the-counter pain relievers, like acetaminophen (Tylenol) and ibuprofen (Advil, Motrin)
Prescription narcotic pain relievers, like codeine
Triptan medications, like sumatriptan (Alsuma, Imitrex, Zecuity)
Steroid medications, especially for headaches caused by cancer that spreads to the brain
Antibiotics, if an infection is causing the headache
Tell your health care team about any over-the-counter pain medication you take.
The following may help reduce the number and severity of headaches:
Get enough sleep.
Some complementary therapies may also help relieve and prevent headaches. This can include techniques such as:
Acupuncture, which is the use of fine needles placed in specific points of the body
Talk with your health care team about controlling your headaches with complementary therapies.
Evaluating Complementary and Alternative Therapies
What To Do When Your Head Hurts
Most of us get headaches from time to time. Some are mild. Others cause throbbing pain. They can last for minutes or days. There are many different types of headaches. How you treat yours depends on which kind you have.
Headaches might arise because of another medical condition, such as swollen sinuses or head injury. In these cases, treating the underlying problem usually relieves headache pain as well. But most headaches—including tension headaches and migraines—aren’t caused by a separate illness.
A headache may feel like a pain inside your brain, but it’s not. Most headaches begin in the many nerves of the muscles and blood vessels that surround your head, neck, and face. These pain-sensing nerves can be set off by stress, muscle tension, enlarged blood vessels, and other triggers. Once activated, the nerves send messages to the brain, and it can feel like the pain is coming from deep within your head.
Tension headaches are the most common type of headache. They can cause a feeling of painful pressure on the head and neck. Tension headaches occur when the muscles in your head and neck tighten, often because of stress or anxiety. Intense work, missed meals, jaw clenching, or too little sleep can bring on tension headaches.
Over-the-counter medicines such as aspirin, ibuprofen, or acetaminophen can help reduce the pain. “Lifestyle changes to relax and reduce stress might help, such as yoga, stretching, massage, and other tension relievers,” says Dr. Linda Porter, an NIH expert on pain research.
Migraines are the second-most common type of headache. They affect more than 1 in 10 people. Migraines tend to run in families and most often affect women. The pain can be severe, with pulsing and throbbing, and can last for several days. Migraine symptoms can also include blurry vision and nausea.
“Migraines are complex and can be disabling,” Porter says. Certain smells, noises, or bright flashing lights can bring on a migraine. Other triggers include lack of sleep, certain foods, skipped meals, smoking, stress, or even an approaching thunderstorm. Keeping a headache diary can help to identify the specific causes of your migraines. Avoiding those triggers or using prescription medications could help prevent or lessen the severity of future migraines.
Be careful not to overuse headache medications. Overuse can cause “rebound” headaches, making headaches more frequent and painful. People with repeating headaches, such as migraines or tension headaches, are especially at risk. Experts advise not taking certain pain-relief medicines for headaches more than 3 times a week.
A less common but more severe type of headache comes on suddenly in “clusters” at the same time of day or night for weeks. Cluster headaches may strike one side of the head, often near one eye, with a sharp or burning pain. These headaches are more common in men and in smokers.
In rare cases, a headache may warn of a serious illness. Get medical help right away if you have a headache after a blow to your head, or if you have a headache along with fever, confusion, loss of consciousness, or pain in the eye or ear.
“Know what kind of headache you have and, if you can’t manage it yourself, seek help,” Porter says. “Remember there are preventive behavioral steps and medicines that can help manage headaches. But if the pain is severe or lasting, get medical care.”
The most common type of headache is tension headache. It is likely caused by tight muscles in your shoulders, neck, scalp, and jaw. A tension headache:
- May be related to stress, depression, anxiety, a head injury, or holding your head and neck in an abnormal position.
- Tends to be on both sides of your head. It often starts at the back of the head and spreads forward. The pain may feel dull or squeezing, like a tight band or vice. Your shoulders, neck, or jaw may feel tight or sore.
A migraine headache involves severe pain. It usually occurs with other symptoms, such as vision changes, sensitivity to sound or light, or nausea. With a migraine:
- The pain may be throbbing, pounding, or pulsating. It tends to begin on one side of your head. It may spread to both sides.
- The headache may be associated with an aura. This is a group of warning symptoms that start before your headache. The pain usually gets worse as you try to move around.
- Migraines may be triggered by foods, such as chocolate, certain cheeses, or monosodium glutamate (MSG). Caffeine withdrawal, lack of sleep, and alcohol may also be triggers.
Rebound headaches are headaches that keep coming back. They often occur from overuse of pain medicines. For this reason, these headaches are also called medicine overuse headaches. People who take pain medicine more than 3 days a week on a regular basis can develop this type of headache.
Other types of headaches:
- Cluster headache is a sharp, very painful headache that occurs daily, sometimes up to several times a day for months. It then goes away for weeks to months. In some people, the headaches never come back. The headache usually lasts less than an hour. It tends to occur at the same times every day.
- Sinus headache causes pain in the front of the head and face. It is due to swelling in the sinus passages behind the cheeks, nose, and eyes. The pain is worse when you bend forward and when you first wake up in the morning.
- Headaches may occur if you have a cold, the flu, a fever, or premenstrual syndrome.
- Headache due to a disorder called temporal arteritis. This is a swollen, inflamed artery that supplies blood to part of the head, temple, and neck area.
In rare cases, a headache can be a sign of something more serious, such as:
- Bleeding in the area between the brain and the thin tissue that covers the brain (subarachnoid hemorrhage)
- Blood pressure that is very high
- Brain infection, such as meningitis or encephalitis, or abscess
- Brain tumor
- Buildup of fluid inside the skull that leads to brain swelling (hydrocephalus)
- Buildup of pressure inside the skull that appears to be, but is not a tumor (pseudotumor cerebri)
- Carbon monoxide poisoning
- Lack of oxygen during sleep (sleep apnea)
- Problems with the blood vessels and bleeding in the brain, such as arteriovenous malformation (AVM), brain aneurysm, or stroke
CASE 2 DIAGNOSIS: HEMICRANIA CONTINUA
The boy was started on a trial of indomethacin at a dose of 25 mg three times daily, with complete resolution of his headaches within two days. He had no further headaches and remained on indomethacin treatment for four months, and then gradually tapered off with no further recurrences. This dramatic and complete response to indomethacin solidified the diagnosis of hemicrania continua.
Headaches are a common problem in children and adolescents. The incidence of headaches in children aged seven years and older is approximately 33%. However, they occur on a frequent basis in approximately 2.5% of the paediatric population. The incidence of headaches in those aged 15 years and older is slightly higher at approximately 50%, with frequent occurrences in approximately 15% of that population. Headaches are known to be more common in boys before puberty, with higher female preponderance postpuberty. General population studies suggest that headaches account for 10% of all school absences. Chronic daily headache presents a particular challenge to the health care provider because several primary and secondary etiologies can have a similar manifestation. Table 1 lists the more common considerations for children presenting with frequent or daily headaches (1).
Causes of chronic daily headaches in children
|Primary headache||Secondary headache|
|Long-duration headaches:||Medication overuse headache|
|Chronic migraine||Raised intracranial pressure (eg, benign intracranial hypertension)|
|Chronic tension-type headache|
|Hemicrania continua||Space-occupying lesion|
|New daily persistent headache||Sinus thrombosis|
|Short-duration headaches:||Infectious origin:|
|Chronic cluster headache||Chronic postinfection headache|
|Chronic paroxysmal hemicrania||Chronic postbacterial meningitis headache|
|Primary stabbing headache|
|Chronic post-traumatic headache|
|Chronic headache attributed to other head or neck trauma|
Indomethacin-responsive headaches (IRHs) are uncommon in paediatrics, but of importance given their rapid and complete response to indomethacin. In fact, the response to indomethacin is effectively diagnostic as well as therapeutic, and may eliminate the need for other more expensive or invasive tests if considered early. The true IRHs seen in the paediatric population are hemicrania continua and paroxysmal hemicrania. With these headaches, a complete response to indomethacin is part of the diagnostic criteria. Exertional headaches and primary stabbing headaches are also highly responsive to indomethacin but do not require a response for diagnosis. Diagnostic criteria for these headache syndromes are itemized in Table 2. Atypical patterns of hemicrania continua and paroxysmal hemicrania, such as bilateral head pain, lack of autonomic features, and temporomandibular and otic pain, do occur in paediatric patients. Consideration should be given for a trial of indomethacin in the setting of persistent daily headache or paroxysmal headaches of short duration that do not fit the typical diagnostic criteria for migraine and/or tension-type headache. However, this needs to be within the context of a normal neurological examination and all secondary causes of headache should be ruled out.
Indomethacin-responsive headaches in children
|Hemicrania continua||Paroxysmal hemicrania||Primary exertional headache||Primary stabbing headache|
Note: Episodic and chronic variants are recognized depending on the presence of remission-free periods of greater than one month
Note: This is often worse in hot, humid weather or high altitude
The diagnostic criteria include no other secondary explanation for the headaches. Data adapted from reference 3
In hemicrania continua, most cases occur in female patients and the age of onset ranges from 10 to 58 years. Patients treated with indomethacin report complete relief of symptoms between 24 h to 72 h after starting treatment. Doses can vary from 50 mg/day to 300 mg/day, with an average of 75 mg/day in divided doses needed for most paediatric patients. A starting dose of 25 mg three times daily is recommended. The dosage should be increased to 50 mg three times per day if the patient has not responded within 48 h. A dose of 100 mg three times daily should be achieved for a week before eliminating the possibility of an IRH. Typically, patients are maintained on indomethacin for at least three months before weaning, but may need a longer term of therapy to avoid headaches (2). Indomethacin was discovered in 1963 for its potent anti-inflammatory, analgesic and antipyretic properties via cyclooxygenase inhibition and prevention of prostaglandin synthesis. The main mechanism in controlling headaches stems from its function as a potent cerebral vasoconstrictor, which is a special property of indomethacin differing from other nonsteroidal anti-inflammatory drugs (NSAIDS). It is known to reduce cerebral blood flow by 18% to 50%, while leaving cerebral metabolism unchanged. Indomethacin also acts as a free radical scavenger and interferes with calcium transport. There is good oral absorption of indomethacin, with a 2 h delay in plasma concentration when consumed with meals. It is 90% plasma bound with 60% renal excretion in 48 h. It is available both orally and rectally.
It is important to recognize the high incidence of side effects with chronic use of indomethacin. Gastrointestinal side effects including dyspepsia, nausea, vomiting, vertigo and gastric bleeding are commonly reported. To prevent gastric adverse effects, antacids, an H2 antagonist or proton pump inhibitor may be co-administered when indomethacin is being used for longer periods. An indomethacin suppository is another option for gastric intolerance or when a higher dose (eg, 300 mg/day) is needed. Interestingly, frontal headache has been reported as a side effect as well. Other rare side effects include hypersensitivity reactions, suicidal behaviour and severe depression, psychosis, and renal impairment. Patients should be cautioned against using other NSAIDs while on indomethacin to avoid potentiating any gastrointestinal side effects. Patients should also be cautioned against using other medications such as anticoagulants, diuretics, methotrexate, cyclosporine and antihypertensive agents. The main contraindication remains in patients in whom acute asthmatic attacks, urticaria or rhinitis are precipitated by administration of this drug or known to have a similar reaction to other NSAIDS.
What is causing this headache?
There are different types of headache.
Share on PinterestEating something very cold can lead to a “brain freeze.”
Tension headaches are the most common form of primary headache. Such headaches normally begin slowly and gradually in the middle of the day.
The person can feel:
- as if they have a tight band around the head
- a constant, dull ache on both sides
- pain spread to or from the neck
Tension-type headaches can be either episodic or chronic. Episodic attacks are usually a few hours in duration, but it can last for several days. Chronic headaches occur for 15 or more days a month for a period of at least 3 months.
A migraine headache may cause a pulsating, throbbing pain usually only on one side of the head. The aching may be accompanied by:
- blurred vision
- sensory disturbances known as auras
Migraine is the second most common form of primary headache and can have a significant impact on the life of an individual. According to the WHO, migraine is the sixth highest cause of days lost due to disability worldwide. A migraine can last from a few hours to between 2 and 3 days.
Rebound or medication-overuse headaches stem from an excessive use of medication to treat headache symptoms. They are the most common cause of secondary headaches. They usually begin early in the day and persist throughout the day. They may improve with pain medication, but worsen when its effects wear off.
Along with the headache itself, rebound headaches can cause:
- neck pain
- a feeling of nasal congestion
- reduced sleep quality
Rebound headaches can cause a range of symptoms, and the pain can be different each day.
Cluster headaches usually last between 15 minutes and 3 hours, and they occur suddenly once per day up to eight times per day for a period of weeks to months. In between clusters, there may be no headache symptoms, and this headache-free period can last months to years.
The pain caused by cluster headaches is:
- often described as sharp or burning
- typically located in or around one eye
The affected area may become red and swollen, the eyelid may droop, and the nasal passage on the affected side may become stuffy and runny.
These are sudden, severe headaches that are often described as the “worst headache of my life.” They reach maximum intensity in less than one minute and last longer than 5 minutes.
A thunderclap headache is often secondary to life-threatening conditions, such as intracerebral hemorhage, cerebral venous thrombosis, ruptured or unruptured aneurysms, reversible cerebral vasoconstriction syndrome (RVS), meningitis, and pituitary apoplexy.
People who experience these sudden, severe headaches should seek medical evaluation immediately.
Like the ringing of an alarm clock, a cluster headache announces itself every morning or night.
If you suffer from cluster headaches, you know that timing is everything. These headaches–called “cluster” because of their pattern of striking in groups or clusters–hit at the same time of day for a period of weeks or months, then vanish as suddenly and as mysteriously as they appeared.
The pain of cluster headaches can be very intense. Most sufferers cannot sit still and will often pace during an acute attack. Often described as having a burning or piercing quality, the pain may be throbbing or constant. The scalp may be tender. Cluster headaches occur more often in men than in women.
Cluster headaches, which are generated by swelling of blood vessels in the head, generally reach their full force within five to 10 minutes after onset. The attacks are usually very similar, varying only slightly from one attack to another.
Malfunction is the trigger
Researchers now believe that cluster headaches, as well as migraines, are triggered by a malfunction of neurotransmitters–in particular, serotonin–which control the action of the blood vessels in the head and neck.
Although the pain of a cluster headache starts suddenly, people usually have a bit of warning that one is on the way. That warning is often a feeling of discomfort or a mild, one-sided burning sensation. Most cluster headaches last only 30 to 45 minutes, but some range from a few minutes to several hours. The headache will disappear only to recur later that day; most sufferers get one to four headaches per day during a cluster period.
Because they occur so regularly, generally at the same time each day, they have been dubbed “alarm clock headaches.”
The headache periods can last weeks or months and then disappear completely for months or years. The cluster headache sufferer has pain-free intervals between episodes. Many cluster headaches occur in the spring or autumn. Because of this, cluster headaches are often mistakenly associated with allergies or business stress. The seasonal relationship is unique for each sufferer. In about 20 percent of cluster sufferers, the attacks may be chronic–they are present throughout the year and do not occur in groups, thus making the control of these headaches more difficult.
The pain of cluster headaches is almost always on one side only and, during a series, the pain remains on the same side. When a new series starts, it can occur on the opposite side. The pain is found behind the eye or in the eye region and may radiate to the forehead, temple, nose, cheek, or upper gum on the affected side. The affected eye may become swollen or droop. The pupil of the eye may contract, and the nostril on the affected side of the head is often congested. Excessive sweating also may occur, and the face may become flushed on the affected side. Unlike migraines, cluster headaches are not associated with gastrointestinal disturbances or sensitivity to light.
During a series, even small amounts of alcohol can bring on an attack. Other substances that cause blood vessel swelling, such as nitroglycerin or histamine, also can provoke an acute attack during a series. Smoking can increase the severity of cluster headaches during a cluster period. During these series, the sufferer’s blood vessels seem to change and become more susceptible to the action of these substances. The blood vessels are not as sensitive to these substances during headache-free periods.
For some people, cluster headaches never disappear. These are known as chronic cluster headaches, and people who have this form of cluster headaches don’t respond to conventional forms of cluster therapy.
If you get cluster headaches, your doctor will prescribe medicine to cut short the length of the cluster period and decrease the severity of the headaches. The medication prescribed helps regulate the chemistry in the brain.
Headaches are extremely common – most people have a headache at some time in their life. Most headaches disappear on their own (with a little time) or with the help of mild pain relievers. Although most headaches are mild and temporary annoyances, some people have headaches that are so severe they need to consult a doctor for pain relief.
Children can also have headaches, some well before they reach the age of 10. Research shows that before puberty, headaches are more common in boys, but that trend is reversed after puberty. Adult women experience more headaches than adult men, and they’re often linked to a woman’s menstrual cycle. With advancing age, both women and men tend to have fewer, less severe headaches.
Headaches come in various forms: tension, migraine, sinus, and cluster headaches. In a small number of cases, headaches may signal a more serious condition that requires immediate medical attention.
Headaches can be triggered by a variety of factors. The most common cause of headaches is prolonged tension or stress. These are called tension headaches or muscle-contraction headaches. Virtually everyone suffers from this at some time. Muscles in your scalp, neck, and face tighten and contract, causing spasms and pain.
Psychological factors such as anxiety, fatigue (e.g., eyestrain), and stress (e.g., long periods of concentration) as well as mechanical factors such as neck strain (e.g., working on a computer for prolonged periods) are often the culprits behind a typical tension headache.
Migraines are generally more severe and can be debilitating. The cause of migraines is not known but many trigger factors are recognized. These include hormonal changes (during a woman’s menstrual cycle or triggered by oral contraceptives), certain foods (e.g., chocolate, aged cheeses), beverages (e.g., red wine, coffee), strong odours, lack of sleep, mild traumatic brain injury (e.g., concussion), and even stress. It is not uncommon to experience mixed tension-migraine headaches.
Sinus headaches are less common than people think. Many people with sinus headaches actually have migraine headaches. They can occur after a bout of upper respiratory infection, such as a cold. Along with the headache, people often have a runny or stuffy nose. Sinus headaches are caused when bacteria invade and infect the nasal sinuses.
Cluster headaches are an uncommon type of headache. They more often affect men, run in families, and tend to occur in clusters over a few days, weeks, or months separated by long headache-free periods lasting from months to years. The cause is not known.
So-called “ice pick” or primary stabbing headaches are severe headaches that occur suddenly, causing a few seconds of intense pain at a small, localized spot. The exact cause of these headaches is unknown, but they are usually not due to a serious problem.
Symptoms and Complications
Tension headaches generally cause a constant pressure or a dull ache that affects the entire head. In most cases it begins slowly, with the ache usually focused above the eyes. There’s a feeling of tightness across the forehead or at the back of the neck. The ache can last for hours or days at a time, with mild-to-moderate pain that is not worsened by activity and that typically improves when the source of tension is relieved.
Cluster headaches occur in “clusters” or groups, with pain lasting about 15 minutes to three hours at a time. The ache and pain is limited to one side of the head and can be extremely severe. They are often accompanied by other symptoms on the side of the headache such as redness and tearing of the eye, drooping eyelid, and nasal stuffiness and dripping.
Migraines range from mild to severe. They often occur as one-sided head pain but can sometimes affect both sides. The location, duration, and intensity of pain vary widely from person to person as well as from one episode to another. Migraine is usually a pulsating pain, often with other symptoms such as nausea, vomiting, visual disturbances, and hypersensitivity to light, noise, and smells. A migraine attack can last from hours to days, averaging 12 to 18 hours per episode. They’re often so severe and incapacitating that many migraine sufferers are unable to carry out normal daily activities.
Migraine headaches are divided into two categories: migraine with aura and migraine without aura. Some people experience a pre-headache stage known as an aura, which can last about 10 to 30 minutes. A typical aura includes visual disturbances such as blind spots, zigzag flashes, and light sparks. The aura normally clears as the headache starts, but there can be some overlap. Sometimes the aura will occur without a headache but more often no aura occurs before the headache.
Although headaches can be painful and debilitating, they are usually not due to dangerous conditions. However, headaches can occasionally be a sign of something more serious. Very severe high blood pressure (above 180/110 mm Hg), stroke, brain tumour, or an aneurysm (a dilated weakened blood vessel) in the brain may cause headaches. Meningitis (an infection of the brain’s lining) may also cause a headache. Warning signs are a sudden onset of headache accompanied by fever, stiff neck, and visual problems (double vision).
It’s critical that you seek emergency medical care if you experience a headache that:
- gets worse over days or weeks
- is accompanied by impaired neurological function (e.g., loss of balance, weakness, numbness, or speech disturbance) and double vision (could signal a stroke)
- is accompanied by persistent nausea and vomiting or changes in vision
- is accompanied by seizures, mental disturbances, and loss of consciousness
- is associated with a fever or stiff neck (could signal meningitis)
- is different than the usual pattern of headaches you have experienced
- strikes suddenly with great intensity
- wakes you from sleep or is worse when you lie down
- has occurred for the first time ever after the age of 40
Making the Diagnosis
If you tend to have headaches that are frequent and severe, your doctor will examine you for any serious, life-threatening conditions (e.g., stroke, meningitis) and start emergency care if needed. As well, if you regularly have headaches and experience a change in the pattern of your usual headaches, you should see your doctor.
Typically, a thorough medical history and physical examination is enough for a good diagnosis. Recording headache frequency, intensity, what you think may have triggered them, as well as medications you have tried may help your doctor make the diagnosis. Since tension headaches are very common, your doctor will ask questions about your current stress level and other personal factors (e.g., work) that may be triggering your headaches. Depending on the location, duration, and any accompanying symptoms, the type of headache can be determined.
In some cases, a brain scan called a CT (computerized tomography) scan or MRI (magnetic resonance imaging) may be used to check for serious causes of headache.
Treatment and Prevention
Since tension headaches are caused by factors such as neck strain, stress, and anxiety, treatment involves eliminating the stressful situation, if possible. Taking an over-the-counter pain reliever such as acetaminophen*, ibuprofen, or naproxen and finding ways to relax, rest, correct poor posture, and regular exercise can all help to relieve and prevent headache pain.
Cluster headaches respond poorly to over-the-counter medications. Oxygen therapy and prescription medications can help.
Sinus headaches usually require antibiotics or other treatments to clear up the infection. Once the infection is gone, the headache will go away, too. Until the infection gets better, taking an over-the-counter pain reliever can help ease the pain.
Migraines can be treated with over-the-counter pain relievers, such as acetaminophen or ibuprofen, if the headaches are mild.
Other medications may need to be prescribed if the headaches are more severe. These can be divided into acute treatments and preventative treatments. Acute treatments are used to try to stop the headache from becoming more severe and to reduce the pain. These include NSAIDs, triptans (e.g., sumatriptan, zolmitriptan), and ergot derivatives (e.g., ergotamine). Acute treatments should be used no more than 10 to 15 days per, month depending on the medication. If used more frequently, they can actually cause headaches called medication overuse headaches.
If you are using acute treatment more than 10 to 15 days per month or you have severely debilitating headaches, your doctor may suggest preventative treatment that is used on a regular basis. The goal of this treatment is to reduce the number of headaches. Some preventative therapy options include beta blockers, anti-depressants, calcium channel blockers, and anti-epileptic medications.
Botulinum toxin (e.g., Botox) is sometimes used for people with chronic migraines (more than 15 days per month) to help reduce the frequency and severity of headaches.
*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For information on a given medication, check our Drug Information database. For more information on brand names, speak with your doctor or pharmacist.
All material copyright MediResource Inc. 1996 – 2020. Terms and conditions of use. The contents herein are for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Source: www.medbroadcast.com/condition/getcondition/Headaches