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A headache is an ache or pain occurring anywhere in the face, neck or head. Headache pain is experienced through pain-sensitive structures around the head and neck including blood vessels, nerves, muscles and tissues including the eyes, ears and sinuses. Headaches can range across the intensity spectrum from mild, tolerable pain to severe pain that prohibits daily activities. Headaches are one of the most commonly experienced causes of pain. They can be occasional, recurrent or chronic in frequency.

The International Classification of Headache Disorders (ICHD) is published by the International Headache Society to classify and diagnose types of headaches. There are many ways of classifying headache. The major distinction is between primary headache (when there is no underlying illness or other cause) and secondary headache (when a specific cause is identifiable). 

If a person has a stable pattern of headache, even if disabling, he or she most likely has a primary headache disorder. Atypical features or recent changes in headache pattern increase the possibility that a headache is secondary to some other medical condition.There are four primary types of headaches: migraines, tension-type headaches, cluster headaches and other headaches sensed in the cranial nerves. Different types of headaches may respond to different types of treatments as they originate by various causes.

Migraines

Migraines are moderate-to-severe, throbbing headaches on both sides or on one side of the head. They are usually situated around the forehead and temples or around the eyes. Migraines occur in women more often than men—usually in patients who have a family history of migraine—and begin between the ages of 10 and 25. These headaches are often associated with nausea, vomiting, loss of appetite, sensitivity to noise, and sensitivity to light. They typically occur 1 to 4 times per month and last most of the day, usually improving with sleep. Some migraines involve an aura of visual changes or numb sensation that spreads in a typical fashion followed by a throbbing headache. Migraines occur in very predictable circumstances or are provoked by the following:

  • Hormonal factors, such as menses, ovulation, oral contraceptives, pregnancy, or after birth

  • Relaxation after stress, such as weekends or vacations

  • Bright lights, such as headlights from cars while driving or fluorescent lights

  • Weather changes, such as altered barometric pressures.

  • Caffeine withdrawal

  • Alteration in sleep patterns, such as sleeping late or lack of sleep

  • Alcohol consumption, especially red wine, champagne, and beer

  • Ingestion of foods, such as chocolates, aged cheeses, hot dogs, deli meats, citrus, yogurt, frozen foods, Chinese food containing MSG, artificially colored foods and beverages, yeast, and canned soups

6% of men and 18% of women are estimated to experience a migraine headache in their lifetime.

Tension-type headaches

These are the most commonly occurring type of primary headache. Up to 9/10 adults will have or have had a tension-type headache in their lifetime.  These headaches are divided into episodic headache days (fewer than 15 per month) and chronic headaches (15 or more headache days per month). The typical episodic headache is the result of localized contraction of the head and neck muscles, associated with stress and fatigue. The chronic headaches are a symptom complex (symptoms that tend to occur together) due, in part, to psychological problems, especially depression. The tension headache is a steady, nonpulsing, persistent ache, often described as a constricting pain (eg, “band-like,” “vice-like,” “weight,” “pressure,” and “tightness”). It may be on one side or both sides of the head, involve the temporal (sides of the head), occipital (back of the head), parietal (top of the head), or frontal (forehead) regions or a combination of these. It can be accompanied by tightness of the neck, upper back, and shoulders with localized areas that are tender to the touch. Blurred vision and sleep disturbance may occur. Vomiting and sensitivity to light and sound are usually absent. A simple tension headache usually lasts a few hours and has no other symptoms.

Cluster headaches

Cluster headache is one of the most severe pain syndromes. Cluster headaches are strictly one-sided and seem to occur at the same time each day (following a person’s circadian rhythm) and may be caused by a problem in the region of the brain (pineal gland) that controls circadian rhythm. Unlike migraine, which primarily affects women, cluster headache mainly affects men. Although the exact incidence is unknown, an estimated 500,000 to 2 million Americans experience cluster headaches.

These excruciatingly painful headaches occur in bursts every year, seemingly more often in the spring and fall than any other time. The cluster period usually lasts between 2 and 3 months. The penetrating and mostly nonthrobbing pain is often felt behind the eyes or in the temple. Attacks can last up to 3 hours and tend to occur at night. The headaches are typically sudden and severe and may be accompanied by watery eyes or a runny nose on the side of the headache. You may feel sweaty, restless, or nauseated. The headaches often start at night and can wake you up. Persons who smoke cigarettes or drink alcohol excessively are more likely to suffer cluster headaches. Many cluster headache sufferers also have peptic ulcers. Women who have cluster headaches may also have a history of migraine.

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If you suffer from frequent headaches, finding out the type of headache causing the majority of symptoms is a critical part of treating the underlying causes of the pain. 

TREATMENTS FOR HEADACHES

The type and cause of the headache must first be determined before proper treatment can be established. Serious (secondary) causes of a headache disorder must first be been ruled out. Some of these secondary causes include conditions such as aneurysms, tumors, infection and inflammation. Fortunately, most headaches are primary, such as migraine or cluster headaches, and once secondary causes for headache have been excluded,  the goal is to correctly diagnose the underlying primary headache disorder. In the majority of the patients this means we are dealing with migraine. The next step is to develop a management plan for the specific headache disorder. This will include education about what we know about the causes of your headache disorder, the potential triggers that may be worsening the headache problem, and discussion about the variety of treatment options for that diagnosis.

Migraines: Migraines can be treated on two fronts: preventive and abortive. Preventative medications seek to avoid the occurrence of a migraine while abortive medications relieve pain after onset. If a patient suffers from recurring migraines, preventive medications may be considered as part of a treatment plan. Preventive medications usually don't eliminate headaches completely, but they can help reduce the severity, length and frequency of migraines. Beta-blockers, calcium blockers, antiseizure medications and antidepressants have all been found potentially effective in preventing the occurrence of migraines in frequent sufferers. If a moderate migraine is underway, a sufferer may find relief from some over-the-counter NSAIDs, or non-steroidal anti-inflammatory drugs such as ibuprofen, or a combination of aspirin and a cola with caffeine. Severe migraines are more effectively treated with triptans for relief of pain, nausea and light and sound sensitivity. A doctor can prescribe triptans, such as sumatriptan, rizatriptan and naratriptan among others.

Tension-type headaches: As tension-type headaches are caused by built up muscle tension in the neck or scalp, a massage may offer some initial pain relief. Over-the-counter pain medications, such as aspirin, ibuprofen, paracetamol, and naproxen can offer effective relief as well. A hot shower or bath or heating pad may also help loosen the muscle tightness causing the pain. Caffeine may also help to relieve tension-type headache pain by dilating blood vessels and increasing blood circulation to the affected muscle region. Treatment options that a doctor may prescribe include narcotic pain relievers, muscle relaxants and certain antidepressants. With the exception of antidepressants, most of the treatments listed above are a means of temporary relief and do not work to prevent the recurrence of tension-type headaches. Lifestyle changes can be adopted to help with the prevention of headaches in the future, including changing sleep habits, increased exercise and stretching the neck, back and shoulder muscles if long periods of time at a desk or computer are a required part of a headache sufferer's job or lifestyle.

Cluster headaches: Unlike other types of headaches, common over-the-counter pain relievers do not typically help abort a cluster headache. Instead, cluster headaches may be relieved by triptans, including sumatriptan and zolmitriptan, narcotics (which are frequently avoided as they are habit forming) and pure oxygen. Pain relief from inhaling 100 percent oxygen can be felt within 15 minutes, however this treatment is most effective before pain reaches its peak, so cluster headache patients may need to have an oxygen cylinder and regulator easily available and accessible. Triptans can be administered in an injectable form or nasal spray as an effective treatment for acute cluster headaches. Preventive strategies for cluster headaches include calcium channel blockers, corticosteroids, ergots, melatonin or antiseizure medications.

HEADACHES