Headache
Patient information: Headache causes and diagnosis in adults
Author
Zahid H Bajwa, MD
R Joshua Wootton, MDiv, PhD Section Editor
Jerry W Swanson, MD Deputy Editor
Leah K Moynihan, RNC, MSN
John F Dashe, MD, PhD
HEADACHE OVERVIEW — Headache is one of the most common medical complaints. Headaches can be quite debilitating, although the vast majority are not due to life threatening disorders. Approximately 90 percent of headaches are caused by one of three syndromes (show table 1):
Migraine headache
Tension-type headaches
Cluster headaches
The causes and diagnosis of non-migraine headaches are discussed here. Migraine headaches are discussed separately. (See “Patient information: Migraine headaches in adults”). A summary of headache treatments is also available. (See “Patient information: Headache treatment in adults”). A discussion of headaches in children is available separately. (See “Patient information: Headache in children”).
TENSION TYPE HEADACHE
Symptoms — Symptoms of tension type headaches (TTH) include pressure or tightness around both sides of the head or neck, mild to moderate pain that is steady and does not throb, and pain that is not worsened by activity. Pain can increase or decrease in severity over the course of the headache. There may be tenderness in the muscles of the head, neck, or shoulders.
People with TTH often note a feeling of mental stress or tension before their headache. Unlike migraine, tension headaches occur without other symptoms such as nausea, vomiting, sensitivity to lights and sounds, or an aura. However, some people have symptoms of both tension and migraine headache.
Clinicians characterize TTH based upon their frequency into three subtypes: infrequent episodic (occurring less than once per month), frequent episodic (occurring one to 14 times per month), and chronic (occurring 15 or more days per month).
People with frequent or chronic TTH often overuse over-the-counter and prescription medications in an attempt to treat their pain. This can lead to medication-overuse headaches (see “Medication-overuse headache” below).
CLUSTER HEADACHE — Cluster headaches are severe, debilitating headaches that occur repeatedly for weeks to months at a time, followed by periods with no headache. Cluster headaches are relatively uncommon, affecting less than one percent of people. In contrast to migraine, men are affected more commonly than women, with a peak age of onset of 25 to 50 years.
Symptoms — The pain of cluster headache begins quickly without any warning and reaches a peak within a few minutes. The headache is usually deep, excruciating, continuous, and explosive in quality, although occasionally it may be pulsatile and throbbing. The attack may occur up to eight times per day but is usually short in duration (between 15 minutes and three hours). The pain typically begins in or around the eye or temple; less commonly it starts in the face, neck, ear, or side of the head. The pain is always on one side; it remains on the same side of the head during a single cluster, but can switch sides during the next cluster in a small percentage of people. Most people with cluster headache are restless and may pace or rock back and forth when an attack is in progress.
Cluster headaches are associated with eye redness and tear production on the side of the pain, a stuffy and runny nose, sweating, a pale appearance, and possibly drooping of the eyelid. Some persons are light sensitive in the eye on the affected side. Other neurologic symptoms are rare. Alcohol can bring on a cluster headache in more than 50 percent of persons who suffer with cluster headaches; this sensitivity to alcohol stops when the cluster ends.
Types of cluster headache — The frequency of attacks depends upon the type of cluster:
Episodic cluster headaches are most common, occurring in 80 to 90 percent of patients suffering from this disorder. They are characterized by pain around the eye that occurs one to three times per day over a four to eight week period, followed by an average pain-free interval of six months to one year. The remission may last for years.
Chronic cluster headaches are characterized by cluster headaches that do not resolve.
Either form of cluster headache can transform into the other. Attacks of pain tend to recur at the same hour each day for the duration of a single cluster, typically between 9:00 pm and 9:00 am. Most people experience one cluster per year, but this is not predictable.
Family history — Cluster headaches can begin at any age. People with cluster headaches are more likely to have family members who also have cluster headaches. First-degree relatives (sibling, child) have a 14-fold increased risk while second-degree relatives (grandchild) have a twofold increased risk of cluster headaches.
CHRONIC DAILY HEADACHE — Some people develop very frequent headaches, as frequent as every day in some cases. When a headache is present for more than 15 days per month for at least three months, it is described as a chronic daily headache.
Chronic daily headache is not a type of headache but a category that includes frequent headaches of various kinds. Most people with chronic daily headache have migraine or tension-type headache as the underlying type of headache. The person may have started out having an occasional migraine or tension-type headache, but the headaches became more frequent over months or years. Some people with frequent headache use headache medications too often, which may lead to the development of “medication-overuse headache” (see “Medication-overuse headache” below).
Medication-overuse headache — Medication-overuse headache (MOH) may occur in people who have frequent migraine, cluster, or tension-type headaches, which leads them to overuse pain medications. A vicious cycle occurs whereby frequent headaches cause the person to take medication frequently (often over-the-counter), which then causes a rebound headache as the medications wear off, causing more medication use, and so on.
MOH is a possible diagnosis in people who have frequent or daily headaches despite (or because of) the regular use of headache medications. Overuse of any number of pain medications can contribute to the development of MOH, including acetaminophen (Tylenol®), butalbital-aspirin-caffeine (Fiorinal®), butalbital-acetominophen-caffeine (Fioricet®, Esgic®) ergotamines, opioids, triptans, and other combinations of medications.
To avoid medication-overuse headache, pain medications should not be used more than nine days per month. Preventive medications may be needed for people who have headaches more frequently. (See “Patient information: Headache treatment in adults” in the section on medication overuse headache).
OTHER TYPES OF HEADACHE — There are a number of other causes of headache.
Migraine headaches — Migraine headaches are discussed separately. (See “Patient information: Migraine headaches in adults”).
Giant cell (temporal) arteritis — This condition is an inflammation of blood vessels that typically occurs in people ages 50 and older. It can cause mild or severe headaches, often with fatigue, generalized aches and pain, and night sweats. Temporary or permanent visual loss is a potential complication. Giant cell arteritis responds to treatment with glucocorticoids such as prednisone.
Sinus headache — Although frequently diagnosed, recurrent headaches related to sinusitis are uncommon. Many, if not most, people diagnosed with sinus headaches actually have migraine headaches. (See “Patient information: Migraine headaches in adults”).
True sinus headache is associated with at least two of the following features:
Nasal pus
Facial pain, pressure, congestion, and fullness
Nasal blockage and discharge
Fever
Decreased or absent ability to smell
Sinus-related pain usually lasts for several days (unlike a typical migraine) and does not cause nausea, vomiting, or sensitivity to noise or light (as seen in migraine). Guidelines for the diagnosis and treatment of sinus headache are presented in table 4 (show table 4) [1,2] .
Post-trauma headaches — Headaches that occur within one to two days after a head injury are relatively common. Most people report a generalized dull, aching, constant discomfort that worsens intermittently. Other common symptoms include vertigo (sensation of spinning), lightheadedness, difficulty concentrating, problems with memory, becoming tired quickly, and irritability.
Post-trauma headaches may continue for up to a few months, although anyone with a headache that does not begin to improve within a week or two after a traumatic event should be evaluated.
HEADACHE DIAGNOSIS — Clinicians typically use a person’s description of their headache, in combination with an examination, to determine the type of headache. Some people have more than one type of headache.
Most people do not need x-rays or imaging tests, although a clinician may recommend a CT scan (or MRI) in some circumstances, for example, if symptoms are not typical of a specific headache syndrome, if there are any danger signs (see “Headache danger signs” below), or if there are any abnormalities seen during the examination. Other possible reasons for brain imaging include:
Headaches that steadily worsen despite treatment
A sudden change in the pattern of headaches
Signs or symptoms that suggest that another medical condition may be causing symptoms
HEADACHE DANGER SIGNS — The vast majority of headaches are not life threatening. However, anyone with the following signs or symptoms should seek medical attention immediately.
A sudden, severe, persistent headache that becomes severe within a few seconds or minutes, or that could be described as “the worst headache of your life”
A severe headache associated with a fever or stiff neck
Headache associated with a seizure, personality changes, confusion, or loss of consciousness
Headache that begins quickly after strenuous exercise or minor trauma
A new headache associated with neurologic symptoms (eg, weakness, numbness, impaired vision). While migraine headaches can sometimes cause these symptoms, a person should be evaluated urgently the first time these symptoms appear.
People with persistent or frequent headaches, headaches that interfere with normal activities, or a change in a previous headache pattern should be seen by a healthcare provider during normal office hours.
Headaches and brain tumor — Headaches occur in approximately 50 percent of people who have brain tumors. However, headaches are very common and brain tumors are rarely found in people who are evaluated for headaches. Many people with brain tumors have chronic headaches that are worse with bending over or occur with nausea and vomiting, although these symptoms can also occur with headaches not related to a brain tumor.
HEADACHE TREATMENT — The treatment of headaches is discussed separately. (See “Patient information: Headache treatment in adults”).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
American Council for Headache Education (ACHE)
(856) 423-0258
(800) 255-2243
(www.achenet.org)
American Headache Society
(856) 423-0043
(www.ahsnet.org)
International Headache Society
(www.i-h-s.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement .
REFERENCES
1 Cady, RK, Dodick, DW, Levine, HL, et al. Sinus headache: a neurology, otolaryngology, allergy, and primary care consensus on diagnosis and treatment. Mayo Clin Proc 2005; 80:908.
2 Levine, HL, Setzen, M, Cady, RK, et al. An otolaryngology, neurology, allergy, and primary care consensus on diagnosis and treatment of sinus headache. Otolaryngol Head Neck Surg 2006; 134:516.
3 Dodick, DW. Clinical practice. Chronic daily headache. N Engl J Med 2006; 354:158.
4 MacGregor, EA, Hackshaw, A. Prevalence of migraine on each day of the natural menstrual cycle. Neurology 2004; 63:351.
5 Silberstein, SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2000; 55:754.
©2009 UpToDate® • customerservice@uptodate.com
www.uptodate.com