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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. Frequent headaches can affect relationships and employment. There is also an increased risk of depression in those with severe headaches.
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 very cold food or beverage, and dental or sinus issues.
A headache is defined as a pain arising from the head or upper neck of the body. The pain originates from the tissues and structures that surround the skull or the brain because the brain itself has no nerves that give rise to the sensation of pain (pain fibers). The thin layer of tissue (periosteum) that surrounds bones, muscles that encase the skull, sinuses, eyes, and ears, as well as thin tissues that cover the surface of the brain and spinal cord (meninges), arteries, veins, and nerves, all can become inflamed or irritated and cause headache. The pain may be a dull ache, sharp, throbbing, constant, intermittent, mild, or intense.
How are headaches classified
In 2013, the International Headache Society released its latest classification system for headache. Because so many people suffer from headaches, and because treatment is difficult sometimes, it was hoped that the new classification system would help health-care professionals make a more specific diagnosis as to the type of headache a patient has, and allow better and more effective options for treatment.
The guidelines are extensive and the Headache Society recommends that health-care professionals consult the guidelines frequently to make certain of the diagnosis.
A. There are three major categories of headache based upon the source of the pain
The different types of headaches depend upon the class they belong to. Some common types include
- Menstrual headaches
- Primary tension headaches that are episodic
- Primary tension headaches that are chronic
- Primary muscle contraction headaches
- Primary migraine headaches with aura
- Primary migraine headaches without aura
- Primary cluster headache
- Primary paroxysmal hemicrania (a type of cluster headache)
- A primary cough headache
- Primary stabbing headache
- A primary headache associated with sexual intercourse
- Primary thunderclap headache
- A hypnic headache (headaches that awaken a person from sleep)
- Hemicrania continua (headaches that are persistently on one side only. right or left [unilateral])
- New daily persistent headache (NDPH) (a type of a chronic headache)
- A headache from exertion
- Trigeminal neuralgia and other cranial nerve inflammation
2. Secondary headaches due to or causes
Secondary headaches are symptoms that happen when another condition stimulates the pain-sensitive nerves of the head. In other words, the headache symptoms can be attributed to another cause.
A wide range of different factors can cause secondary headaches.
Eating something very cold can lead to a “brain freeze
- Traumatic Disorder
- Structural problems with the bones of the face, teeth, eyes, ears, nose, sinuses or other structure
- Substance abuse or withdrawal alcohol-induced hangover brain tumor blood clots bleeding in or around the brain”brain freeze,” or ice-cream headaches carbon monoxide poisoning concussion dehydration glaucoma teeth-grinding at night influenza overuse of pain medication, known as rebound headaches panic attacks stroke
3. Others Type of headache
- Pregnancy headaches
- Rebound headaches
- Sinus headaches
- Spinal headaches
- Caffeine headaches
- Menstrual headaches
- Cough headaches
- Exertion headaches
- Hangover headaches
- Hypertension headaches
- Tumor headaches
- Meningitis and encephalitis headaches
- Post-traumatic headaches
- Temporal arteritis
- cranial neuralgias, facial pain, and other headaches.
B. The symptoms of a headache can depend on the type.
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 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
A migraine is the second most common form of a 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 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 a 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 hemorrhage, cerebral venous thrombosis, ruptured or unruptured aneurysms, reversible cerebral vasoconstriction syndrome (RVS), meningitis, and pituitary apoplexy.
Type of pain -Many patients suffer from more than one type of a headache. This may result from different etiologic factors or may represent a change in the character of a chronic headache disorder.
Temporal profile of pain – Acute-onset headaches of severe intensity occurring in a patient without a previous history of similar headaches may suggest an organic etiology. The timing of onset and association with sleep or hormonal cycles may be helpful in diagnosis.
Characteristics of pain – The location, duration, and quality of pain should be carefully evaluated. Location may be diffuse, either unilateral or bilateral, or localized to specific structures in the head and neck. Vascular headaches produce throbbing pain; constant pain results from myogenic or traction headaches. The intensity of pain is not a reliable indicator of the seriousness of underlying conditions causing the headache.
Prodromes – Neurologic symptoms may precede a classic migraine headache. Visual symptoms such as scintillations, scotoma, or hemianopsia are most common; other symptoms, such as hemiplegia or ophthalmoplegia, occur rarely. Patients with a common migraine may report vague premonitory symptoms such as malaise or psychic disturbances.
Precipitating factors –Association of a headache with environmental factors may be helpful in diagnosis. Foods such as alcohol or those containing tyramine or sodium nitrates may precipitate vascular headaches. Some patients report an association with menstruation. Medications, including nitrates and other vasodilators, indomethacin, and oral contraceptives can aggravate or induce a headache. Occupational factors can produce mechanical influences that aggravate a headache. A history of frequent neck movements, exposure to bright lights, or long periods of work at video terminals may be helpful.
Associated symptoms –a Headache associated with progressive neurologic deficits or seizures can indicate an intracranial lesion. Meningeal signs occurring with an acute violent headache suggest subarachnoid hemorrhage. A migraine is commonly a “sick headache” associated with nausea, anorexia, photophobia, or sonophobia. Autonomic symptoms such as lacrimation, nasal congestion, facial flushing, or Horner’s syndrome accompany cluster headaches.
Medical history – A headache with onset after head trauma may suggest subdural hematoma. The previous history of malignancy or systemic disease may suggest an etiology of a headache. Family history should be investigated because a migraine is commonly familial. Prior investigations into a patient’s headache, including attempted therapeutic interventions, should be carefully evaluated.
Causes of Headaches
- Headache pain results from signals interacting among the brain, blood vessels, and surrounding nerves. During a headache, specific nerves of the blood vessels are activated and send pain signals to the brain. It’s not clear, however, why these signals are activated in the first place.
- There is a migraine “pain center,” or generator, in the midbrain area. A migraine begins when overactive nerve cells send out impulses to the blood vessels. This causes the release of prostaglandins, serotonin, and other substances that cause swelling of the blood vessels in the vicinity of the nerve endings, resulting in pain.
- Headaches that occur suddenly (acute onset) are usually caused by an illness, infection, cold, or fever. Other conditions that can cause an acute headache include sinusitis (inflammation of the sinuses), pharyngitis (inflammation or infection of the throat), or otitis (ear infection or inflammation).
In some cases, the headaches may be the result of a blow to the head (trauma) or, rarely, a sign of a more serious medical condition.
Common triggers of tension-type headaches or migraine headaches include
- emotional stress related to family and friends, work, or school
- alcohol use
- skipping meals
- changes in sleep patterns
- excessive medication use
Other causes of headaches include eye strain and neck or back strain caused by poor posture.
When headaches become progressive and occur along with other neurological symptoms, they can be the sign of a disease process in the brain, such as:
- hydrocephalus (abnormal buildup of fluid in the brain)
- meningitis (an infection or inflammation of the membrane that covers the brain and spinal cord)
- encephalitis (infection/inflammation of the brain)
- hemorrhage (bleeding within the brain)
- blood clots along the surface of the brain
- head trauma
- toxins (overexposure to chemicals, including certain medications)
The American Headache Society recommends using “SNOOP”,
A mnemonic to remember the red flags for identifying a secondary headache:
- Systemic symptoms (fever or weight loss)
- Systemic disease (HIV infection, malignancy)
- Neurologic symptoms or signs
- Onset sudden (a thunderclap headache)
- Onset after age 40 years
- Previous headache history (first, worst, or a different headache)
Other red flag symptoms include
|Red Flag||Possible Causes||The reason why the red flag indicates possible causes||Diagnostic tests|
|New headache after age 50||Temporal arteritis, mass in the brain||Temporal 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 (a 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 cause 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 severity||Mass, subdural hematoma, medication overuse||As 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|
|A 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 indicate 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|
|A severe headache following head trauma||Brain bleeds (intracranial hemorrhage, subdural hematoma, epidural hematoma), post-traumatic headache||Trauma can cause bleeding in the brain or shake the nerves, causing a post-traumatic headache||Neuroimaging of brain, skull, and possibly cervical spine|
|Inability to move a limb||Arteriovenous malformation, collagen vascular disease, intracranial mass lesion||Focal neurological signs indicate something is pushing against nerves in the brain responsible for one part of the body||Neuroimaging, blood tests for collagen vascular diseases|
|Change in personality, consciousness, or mental status||Central nervous system infection, intracranial bleed, mass||Change in mental status indicates a global infection or inflammation of the brain, or a large bleed compressing the brainstem where the consciousness centers lie||Blood tests, lumbar puncture, neuroimaging|
|A headache triggered by a cough, exertion or while engaged in sexual intercourse||Mass lesion, subarachnoid hemorrhage||Coughing and exertion increase the intracranial 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, lum
- Tricyclic antidepressants – These are older antidepressant drugs that include amitriptyline (Elavil), doxepin (Silenor, Sinequan), nortriptyline (Pamelor), and protriptyline (Vivactil).
- Migraine drugs called triptans – Some examples are almotriptan (Axert), frovatriptan (Frova), sumatriptan (Imitrex), and zolmitriptan (Zomig).
- NSAIDs (nonsteroidal anti-inflammatory drugs) – These painkillers include aspirin, celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen, and naproxen.
- Amitriptyline – Tricyclic antidepressant amitriptyline has been most extensively studied and has been found to most effective for the treatment of CTTH.[rx] Way back in 1964, Lance et al. conducted the first controlled crossover trial and demonstrated the superiority of amitriptyline over placebo in patients with CTTH.[rx] Since then, a number of studies tested the various doses and compared amitriptyline with other antidepressants like citalopram.[rx–rx] By and large, doses upto 75 mg of amitriptyline were found to be useful. Mechanism of action of amitriptyline in CTTH is uncertain. Possible explanations include serotonin reuptake inhibition, potentiation of endogenous opioids, NMDA receptor antagonism and blockade of ion channels.[rx]Amitriptyline should be started on low dose (10 mg to 25 mg per day) and titrated by 10-25 mg weekly till the therapeutic effect or the side effects appear. Significant clinical effect of Amtriptlyline is usually seen by the end of one week and should be apparent by 3-4 weeks.[rx]
- Other antidepressants – like SSRIs and tetracyclic have been found to be not so useful. Although studies have found a modest effect on prevention of CTTH by drugs like citalopram,[rx] sertraline, mianserin,[rx] fluvoxamine,[rx] paroxetine,[rx] venlafaxine (extended release)[rx] and a D2 antagonist sulpiride,[rx] there are no robust data for recommending these agents yet. A new drug, mirtazapine,[rx] a noradrenergic and serotonergic antidepressant however has been found to be efficacious and can be given in situations where amitriptyline is either ineffective or contraindicated. At a dose of 30 mg/day, it reduced headache index by 34% more than placebo in difficult-to-treat patients, including patients who had not responded to amitriptyline.
- The role of muscle relaxants in the prevention of CTTH is debatable. Centrally acting muscle relaxant like tizanidine may have some benefit but is not recommended routinely. Peripherally acting muscle relaxants have no role. At least 3 studies have tested tizanidine in CTTH and while two studies[rx,rx] showed modest benefit, one failed to show any.[rx]
Botulinum toxin type A
- Following an open labeled study in which Botulinum Toxin Type A injection was shown to be efficacious in CTTH patients,[rx] few controlled studies have been undertaken.[rx–rx] The results have been conflicting and largely negative. Hence, Botulinum Toxin Type A is not recommended for CTTH prevention.
Non-pharmacologic management includes physical therapy and psychologic treatment. Ideally these should be tried in all patients as adjuncts to pharmacotherapy. These may however be more attractive to patients reluctant to use drugs.
- Physical therapy – It is the most commonly used non-pharmacologic treatment of TTH. Its components include improvement of posture, relaxation, exercise programs, hot and cold packs, ultrasound, and electrical stimulation.[rx] Active treatment strategies generally are recommended. A controlled study combining various techniques, such as massage, relaxation, and home-based exercises found a modest effect.[rx] Adding craniocervical training to classical physiotherapy may be better than physiotherapy alone.[rx]
- Psychologic therapy – This includes relaxation training, EMG biofeedback and cognitive-behavioral therapy.[rx] During relaxation training, the patients consciously reduce muscle tension and autonomic arousal that can precipitate and result from headaches. Thus, it is a strategy for training in self-regulation. EMG biofeedback helps the patients to develop control over pericranial muscle tension. The patients use the feedbacks that are presented with an auditory or visual display of electrical activity of the muscles in the face, neck, or shoulders. It is uncertain whether reductions in muscle tension or cognitive changes of self-efficacy account for improvement. The latter is more likely. In cognitive-behavioral therapy, patients are taught to identify thoughts and beliefs that generate stress and aggravate headaches. Although treatment outcome of psychologic therapies is difficult to measure, there seems to be reasonable scientific support for their effectiveness.
- Miscellaneous treatments – Oromandibular treatment with occlusal splints is an attractive option but lack scientific data and hence not recommended for routine use.[rx] Similarly for acupuncture, there are conflicting results regarding its efficacy for the treatment of TTH.[rx–rx] Spinal manipulation has shown no effect on the treatment of episodic TTH.[rx]
Sometimes the overuse of analgesic medicines causes a condition called medication overuse headache, or rebound a headache.
- Headache education – includes identifying and recording what triggers your headache, such as lack of sleep, not eating at regular times, eating certain foods or additives, caffeine, environment, or stress. Avoiding headache triggers is an important step in successfully treating the headaches.
- Counseling – in the form of one-on-one sessions, group therapy, or support groups can help you identify your headache triggers and teach you useful coping techniques.
- Stress management – To successfully treat headaches, it is important for you to identify what causes or triggers the headaches. Then you can learn ways to cope with or remove the stressful activities or events. Relaxation techniques are helpful in managing stress and include deep breathing exercises, progressive muscle relaxation, mental imagery relaxation, or relaxation to music. Ask your health care provider for more information about these techniques.
- Biofeedback – Biofeedback equipment includes sensors connected to your body to examine your involuntary physical responses to headaches, such as breathing, pulse, heart rate, temperature, muscle tension, and brain activity. By learning to recognize these physical reactions and how the body responds in stressful situations, biofeedback can help you learn how to release and control tension that causes headaches
- Chiropractic Care – Chiropractors don’t merely treat symptoms, instead, they look for causes, ” says a busy chiropractor in Dupage County, IL. “Many people have been taught to be skeptical of chiropractors because they really don’t understand what we do.”These Chicago chiropractors want to help. How can they eliminate your headache symptoms without drugs? Chiropractors are trained to use gentle and safe spinal adjustment techniques that can relieve any nerve interference that is causing your headache
Home Remedies for Headaches