Headache

Dr. Ravindra Patil on October 8, 2021

Headache

A headache is a very common condition that causes pain and discomfort in the head, scalp, or neck. It’s estimated that 7 in 10 people have at least one headache each year. It is one of the most common symptoms suffered by the human race. It is of various types and there are literally hundreds of causes for head ache. Luckily most cases of head ache can be easily treated, but persistent, long standing, severe headaches need through investigations to find their cause. Then the cause can be treated. It is worth remembering that some headaches may be symptoms of grave brain disease.

Table of Contents

How it occurs

Head Ache is defined as 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 fibres). 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 a Head Ache. The pain may be a dull ache, sharp, throbbing, constant, intermittent, mild, or intense.

Common types of headaches

Some common headaches are throbbing, squeezing, constant, unrelenting, or intermittent. The location may be in one part of the face or skull or may be generalized involving the whole head.

It may arise spontaneously or may be associated with activity or exercise. It may have a sudden onset or it may be start slowly in persist. This is called chronic head ache. The severity may increase in subsequent episodes of chronic head ache.

Head Ache is often associated with nausea and vomiting. This is especially true with migraine headaches and headaches because of head injury.

Classification of headaches

Head pain can be classified as follows:

1) Primary Head Ache: Common primary headaches include tension headaches, migraines, and cluster headaches.

Tension headaches are the most common type of primary head Ache. Tension headaches occur more commonly among women than men. According to the World Health Organization (WHO), 1 in 20 people in the developed world suffer with a daily tension head Ache.

Migraine headaches are the second most common type of primary head Ache. Migraine headaches affect children as well as adults. Before puberty, boys and girls are affected equally by migraine headaches, but after puberty, more women than men are affected.

Cluster headaches are rare but need intense management.

2) Secondary Headache: Secondary headaches are headaches that are due to an underlying medical condition, such as a head injury, neck injury, a sinus infection or a dental pain. Rarely, a secondary Head Ache may be a sign of a serious underlying medical condition such as brain infection [encephalitis] or an abscess or a cerebral haemorrhage.

3) Cranial Neuralgias: facial pain, and other headaches.

4) Medication overuse head ache, also called as ‘rebound Head Ache’: It is a condition where frequent use of pain medicines can lead to persistent headaches. The Head Ache may improve for a short time after the medication is taken and then recur.

Causes of Headache

Secondary head aches are usually a symptom of an injury or an underlying illness. For example, sinus headaches are considered a secondary head aches due to increased pressure or infection in the sinuses within the bones of the skull.

HeadAche patients should seek medical advice for new head aches or if head aches are associated with fever, stiff neck, weakness, change in sensation on one side of the body, change in vision, vomiting, or change in behaviour.

Traumatic [caused because of injury] headaches fall into this category including post-concussion headaches.

This group of head aches also includes those headaches associated with substance abuse and excess use of medications used to treat it (medication overuse headaches). “Hangover” head aches after a bout of alcohol abuse fall into this category as well. People who drink too much alcohol may waken with a well-established head ache due to the effects of alcohol and dehydration.

Tension Headaches

It is a mild to moderate pain often described as feeling like a tight band around the head. The signs and symptoms of tension head ache are:

  1. Pain that begins in the back of the head and upper neck and is often described as a band-like tightness or pressure. It may spread to encircle the head. Headache in the back head can be due to tention head aches
  2. The most intense pressure may be felt at the temples or over the eyebrows where the temporalis and frontal muscles are located.
  3. The pain may vary in intensity but usually is not disabling, meaning that the sufferer may continue with daily activities. The pain usually is bilateral (affecting both sides of the head).
  4. The pain is not associated with an aura (see below), nausea, vomiting, or sensitivity to light and sound.
  5. The pain occurs sporadically (infrequently and without a pattern) but can occur frequently and even daily in some people.
  6. The pain allows most people to function normally, despite the pain in head.

What causes tension headaches?

While tension head aches are the most frequently occurring type of head ache, their cause is not known. The most likely cause is painful contraction or spasm of the muscles that cover the skull and in the upper portion of the neck and shoulders. When the muscles covering the skull are stressed, they may become inflamed, go into spasm, and cause pain. Common sites or tension head ache are the base of the skull where the trapezius muscle of the neck is attached and the temporal region of the skull where the temporalis muscles [the muscles which move the lower jaw] are attached to the skull on either side.

Diagnosis of Tension Headaches

The key to making the diagnosis of any head ache is the history given by the patient. The doctor will ask questions about the quality, intensity and duration of the pain and associated symptoms.

The tension head ache patient will usually complain of mild-to-moderate pain that is located on both sides of the head. People with tension head aches describe the pain as a non-throbbing tightness, that is not made worse with activity. There usually are no associated symptoms like nausea, vomiting, or sensitivity to light.

The neurological examination of the patient is important in tension head aches to make the diagnosis. There may be some tenderness of the scalp or neck muscles. If the doctor finds an abnormality on neurological examination, the diagnosis of tension head ache will be put on hold until the possibility of other causes of head aches has been excluded.

Treatment of Tension Headaches

Even though it is not a life-threatening condition, a tension head ache can make daily activities more difficult to accomplish. Most people treat themselves successfully with Over-the-Counter (OTC) pain medications to control tension head aches. The following work well for most people:

  1. Aspirin
  2. Ibuprofen
  3. Paracetamol for headache
  4. Naproxen

Recurrent head aches is a signal to seek expert medical help. Physical therapy, massage and stress management can all be used as adjuncts to help control tension head aches.

It is important to remember that OTC headache medicine while safe, may have side effects and potential interactions with other prescribed medicines. It always is wise to consult a doctor about using OTC medications. This important because OTC pain medications may have to be used for a long time.

For example, some OTC medications include caffeine, which may trigger increase in the heart rate in some patients. Some OTC cold medications have pseudoephedrine mixed in with the pain medication, which may elevate the blood pressure and induce palpitations.
Aspirin, ibuprofen, and naproxen may cause stomach burn and rarely ulcers. They should be used with caution in patients who have peptic ulcer disease. Aspirin must be used cautiously with blood thinner medicines. Overuse of aspirin, ibuprofen, and naproxen also may cause kidney damage.

Cervicogenic headaches

Cervicogenic head aches occur when intervertebral discs in the cervical vertebrae start to degenerate and press on the spinal column. The result can be significant neck pain as well as head aches. The pain will also extend to the limbs and other parts of the body.

Rebound Headaches

Medication overuse head ache can be mistaken for chronic tension head aches. When pain medications are used for a prolonged period, head aches may recur when the effects of the medication wear off. This type of head ache is also referred to as a “rebound headache”, and is classified as a secondary head ache.

Cranial Neuralgias, Facial Pain, and such Headaches

Neuralgia means nerve pain. Cranial neuralgia describes inflammation of one of the 12 cranial nerves coming from the brain that control the muscles and carry sensory signals (such as pain) to and from the head and neck. Perhaps the most commonly recognized example is trigeminal neuralgia, which affects cranial nerve V (the trigeminal nerve), the sensory nerve that supplies the face and can cause intense facial pain when irritated or inflamed.

Trigeminal Neuralgia

Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from our face to our brain. Trigeminal Neuralgia patients will get a pain attack with even mild stimulation of their face such as from brushing teeth or applying makeup. Such activity may trigger a jolt of severe pain.

Diagnosis of Trigeminal Neuralgia

There’s no specific test for trigeminal neuralgia, so a diagnosis is usually based on the patient’s symptoms and description of the pain. For attacks of facial pain, the doctor will ask you questions about your symptoms, such as: how often do the pain attacks happen and how intense the pain is.

Treatment of Trigeminal Neuralgia

Carbamazepine is the gold standard in treating this chronic condition. Gabapentin is also used. Newer medications are being developed. All such medicines should be strictly taken after prescription and should be monitored by a doctor.

Complications of spinal tumours

Spinal tumours can compress spinal nerves, leading to a loss of movement or sensation below the location of the tumour. This can sometimes cause changes in bowel and bladder function. Nerve damage may be permanent.

However, if a spinal tumour is diagnosed early and treated properly, it may be possible to prevent further loss of function and regain nerve function.

Depending on its location, a tumour that presses against the spinal cord itself may be life-threatening.

Cluster Headaches

Cluster headaches are a rare type of primary head ache. They more commonly affect men in their late 20s, https://zonatuninga.com.ua though women and children can also suffer from this type of headache.

Cluster headaches occur in cyclical patterns or “cluster periods”. They are one of the most painful types of headaches. A cluster head ache commonly awakens patients in the middle of the night with intense pain in or around one eye on one side of the head. This is why you get head ache behind eyes. Bouts of frequent attacks, known as cluster periods, may last from weeks to months, usually followed by long periods of relief (remission). During remission, attacks may stop for months or years.

Pain is severe on one side of the head, accompanied by symptoms such as nasal discharge, red eyes, and excessive tears in the eyes.

There are various treatments for cluster head aches, but patients can be treated only after a thorough investigations workup.

Triggers of Cluster Headaches

The following may trigger cluster head aches:

  1. Alcohol use or smoking cigarettes
  2. Change to a high altitude
  3. Bright light
  4. Exercise or exertion
  5. Heat, from either the weather or a bath
  6. Foods that contain nitrates, such as certain types of meat
  7. Drug abuse

Symptoms of cluster headaches

  1. Sudden onset of pain, generally around or behind one eye
  2. Pain builds to a peak in about 10 to 15 minutes
  3. Restlessness or agitation
  4. Red or watering eyes
  5. Nasal congestion
  6. Sweating on the forehead
  7. Eyelid drooping or swelling

The symptoms of a cluster head ache may look like other health conditions. It is advisable for cluster head ache patients to consult their physician for a proper diagnosis.

Diagnosis of Cluster Headaches

Diagnosis is done mostly on history where the pattern of near daily head aches that come back again and again for days, weeks, or months is discussed and noted.

Treatment of Cluster Headaches

A two-pronged approach is used for the treatment of cluster head aches:

a. For treating an attack: To stop or at least control an attack in progress, the patient may be given high-dose oxygen therapy through a face mask for 15 to 20 minutes. A prescription medicine through a nasal spray can be used.

b. For preventing future attacks: The second part of cluster head ache treatment is to prevent recurrent attacks by taking medicines daily. Some of the medicines used to prevent cluster head aches are:

c. A medicine that relaxes blood vessels.

d. A steroid that reduces inflammation and swelling.

e. Lithium carbonate. A medicine that restores the balance of certain brain chemicals.

f. Anti-seizure medicines. These medicines may help reduce the frequency of cluster head aches.

Complications of Cluster Headaches

A real cluster head ache is not life threatening. It does not cause permanent brain damage. But it tends to persist for a long time [chronic] and recurs often. Cluster headaches interfere with the patient’s lifestyle and work.

Prevention of Cluster Headaches

To prevent a cluster head ache, it’s important to find out what triggers the head aches.

Avoiding smoking and alcohol is the best advice.  Notes can be made about what the patient was doing, eating, or drinking when the head ache started and the same can be shared with the doctor. The notes will help the doctor prescribe medicine and a management plan that will help prevent cluster head aches.

Some medicines help prevent cluster head aches. 

When to seek treatment in Cluster Headaches

Patients must seek treatment as soon as possible, because no one can say with certainty whether a severe recurring head aches are a cluster head ache or a sign of a grave brain disease. But the in case the patient has the following signs, it is highly advisable to seek an immediate consultation.

  1. Changes in alertness
  2. Loss of movement or sensation
  3. Drowsiness
  4. Nausea or vomiting
  5. Seizure activity
  6. Changes in vision 

Cluster Headaches: Key points

  1. Cluster head aches occur in groups, or clusters, and each attack lasts about 1 to 3 hours on average.
  2. They may occur every other day to multiple times a day.
  3. Cluster periods are followed by remissions that may last months or years.
  4. Compared with other types of primary head aches, cluster head aches are rare.
  5. The pain they produce is severe, and they tend to recur in the same way each time
  6. Finding out head ache triggers may help prevent their occurrence.
  7. A true cluster head ache is not life-threatening and does not cause permanent brain damage.

Migraine headaches

Migraine head aches are severe head aches that can cause throbbing, pounding pain, usually on one side of the head. Several different types of migraine head ache exist. This includes chronic migraines, which are migraines that occur 15 or more days a month. “Migraine on its own was found to be the sixth highest cause worldwide of years lost due to disability” as per WHO.

Migraines are very intense, throbbing headaches that affect one side of the head. They can also increase sensitivity to light and noise. They may last anywhere from several hours to several days. Oftentimes, TMJ headache is misunderstood as migraine head ache, however they are very much different.

Migraines are the most severe and complex type of head ache. Researchers believe they may be caused by changes in the activity of nerve pathways and brain chemicals. Genetic factors and environmental factors are also thought to affect a person’s susceptibility to developing migraines.

Incidence and types of migraines

Migraines are one of the top 20 most disabling illnesses in the world.

Among adolescents, migraines are more common in boys than in girls. Among adults, however, migraines occur more frequently in women than in men. They are also more likely to affect those who have family members that often experience migraines.

There are two basic types of migraine head aches: migraine with aura and migraine without aura. Auras are visual disturbances that consist of bright spots, flashing lights, or moving lines. In some cases, auras cause a temporary loss of vision. These visual disturbances occur about 30 minutes before the migraine begins and can last for 15 minutes.

Migraine with aura tends to be less severe and disabling than migraine without aura. However, most people experience migraines without aura.

Hemiplegic migraine is another type of migraine. It is accompanied by stroke-like symptoms, such as slurred speech and numbness or weakness on one side of the body.

Migraine phases

Migraines have three phases: prodrome, peak head ache, and postdrome.

  • Prodrome is the period leading up to the migraine. This is the time when auras can occur. The prodrome phase may affect concentration, mood, and appetite. This phase may also cause frequent yawning.
  • Peak head ache is the period when migraine symptoms become the most severe. This phase may last for several minutes.
  • Postdrome is the 24-hour period after the migraine. During this time, drowsiness can occur and mood can fluctuate between feelings of sadness and feelings of joy.

Migraine triggers

The exact cause of migraines isn’t known. However, there are numerous factors that are known to trigger the onset of migraine episodes. Some of them are:
  1. Fluctuating hormone levels, especially among boys going through puberty, and women
  2. Stress or anxiety
  3. Fermented and pickled foods
  4. Cured meats and aged cheeses
  5. Certain fruits, including bananas, avocados, and citrus fruits
  6. Skipped meals
  7. Too little or too much sleep
  8. Bright or strong lights
  9. Fluctuations in atmospheric pressure due to changing weather
  10. Alcohol consumption
  11. Caffeine withdrawal

Treatment for Migraine

Migraine head aches can be treated at home. Perhaps the oldest medicine combination for migraine is aspirin, paracetamol and caffeine. Beta-blockers are one of the preventive medication options for migraine, but must be prescribed by a doctor and the effects of betablocker on the patient should be monitored.

Prescription medications are available to abort or stop the head ache. Sumatriptan is a prescription medicine used often for migraine. Other medications are available to treat the nausea and vomiting. Most patients with migraine head aches get much relief after resting in a dark room and falling asleep. To summarise, the following steps will help reduce the pain of migraine.

  1. Cold Pack.
  2. Heating Pad or Hot Compress on the head.
  3. Dim the Lights.
  4. Try Not to Chew.
  5. Drink enough water.
  6. Get Some Caffeine.
  7. Practice Relaxation.

Secondary Headaches

Secondary head aches are due to an underlying disease or injury that needs to be diagnosed and treated. Controlling the head ache may have to be done at the same time that diagnostic testing is performed to identify the underlying disease. Some of the causes of secondary head ache may be potentially life threatening and deadly. Early diagnosis and treatment is essential if permanent damage is to be limited. Some of the common reasons for secondary head ache are:

Head and Neck Injuries

Injuries to the head may cause bleeding in the spaces between the meninges [layers that cover the brain], subdural, epidural, and subarachnoid spaces or within the brain tissue itself [intracerebral haemorrhage]. Oedema or swelling within the brain not associated with bleeding may cause pain and a change in mental function.

Concussions, where head injury occurs without bleeding. Head ache with nausea and vomiting is one of the hallmarks of post-concussion syndrome.

Some conditions which cause head ache are whiplash neck injury [where the neck is suddenly moved], blood vessel malformations or diseases in the head and neck, stroke or Transient Ischemic Attack (TIA), Arteriovenous Malformations (AVM) when they leak and so on.

Carotid artery inflammation, temporal artery inflammation and brain tumors also cause head aches.

Cerebral aneurysm and subarachnoid haemorrhage

An aneurysm is a weakened area in a blood vessel wall. It can expand and leak a small amount of blood and cause head ache. This may be a warning sign of a future catastrophic bleed into the brain.

Increased Intracranial Pressure

When the pressure around the brain, called intra cranial pressure, increases because of injury or infection or inflamatin, the patient suffers head ache.

Medications which may cause Headache

Oral contraceptives, medications used to treat erectile dysfunction, blood pressure or other cardiac medications can all cause head aches.

Head ache because of Medication overuse occurs when pain relieving medications are taken too frequently. Over the counter analgesics with caffeine and narcotic analgesics may cause withdrawal head ache.

Other causes of Secondary Headache

Head ache is such a common symptom because there are many conditions where there is pain in the head. Examples are:

  1. Fever
  2. Meningitis
  3. Encephalitis
  4. HIV/AIDS
  5. Systemic infections, for example, pneumonia or influenza
  6. Changes in the body’s environment like low or high atmospheric pressure, temperature etc
  7. High blood pressure [hypertension]
  8. Dehydration
  9. Hypothyroidism
  10. Kidney dialysis
  11. Problems with the eyes, ears, nose throat, teeth, sinuses, and neck
  12. Sinus infection
  13. Dental pain
  14. Glaucoma
  15. Iritis

Diagnosis of Secondary Headaches

Diagnosis of secondary head ache begins with a complete patient history followed by a physical examination and laboratory and radiology tests as appropriate.

However, some patients complaining of head ache present in a crisis with a decreased level of consciousness or unstable vital signs due to some grave underlying cause of the head ache. In these situations, the treating doctor may decide to begin treatment without waiting for history or tests to confirm the diagnosis.

For example, a patient with head ache, fever, stiff neck, and confusion may have meningitis. Since meningitis can be fatal, antibiotic therapy may be started before blood tests and a lumbar puncture are performed to confirm the diagnosis.

Diagnostic Tests for Secondary Headaches

The patient history and physical examination provide the initial direction for determining the cause of secondary head aches. Therefore, it is extremely important that a detailed history of patients with a new, severe head ache is taken either from the patient or from the person attending him/her.

Tests that may be useful in making the diagnosis of the underlying disease causing the head aches will depend upon the doctor’s evaluation and what specific disease, illness, or injury is being considered as the cause of the head aches. Common tests that are:

Blood Tests

An infection or inflammation in the body may cause a rise in the white blood cell count, the Erythrocyte Sedimentation Rate (ESR), or C-reactive Protein (CRP). These two tests are very nonspecific but helpful when done along with other tests. Blood tests also help assess electrolyte imbalance, and a variety of other potential problems involving vital organs like the liver, kidney and thyroid. Toxicology tests may be helpful if the patient is suspected of abusing alcohol, prescription medicines or other abuse drugs.

CT Scan of the head

Computerized tomography (CT scan) is able to detect bleeding [haemorrhage], swelling, and some tumours within the skull and brain. It also can show evidence of a previous stroke. With intravenous contrast injection (angiogram), it may also be used to look at the arteries of the brain for aneurysms.

Magnetic resonance imaging (MRI) of the head

MRI is able to show the anatomy of the brain and the layers that cover the brain and the spinal cord (meninges). It is more precise than computerized tomography. This type of scan is not available at all hospitals. Moreover, it takes much longer to perform, requires the patient to cooperate by holding still, and requires that the patients have no metal in their body (for example, a heart pacemaker or metal foreign objects in the eye). Besides critically ill patients sometimes cannot undergo MRI testing.

Lumbar puncture

Cerebrospinal fluid, the fluid that surrounds the brain and spinal cord, can be obtained with a needle that is inserted into the spine in the lower back. Examination of the fluid looks for infection (such as meningitis due to bacteria, virus, fungus, or tuberculosis) or blood from haemorrhage. In almost all cases, computerized tomography is done prior to lumbar puncture to make certain there is no bleeding, swelling, or tumour within the brain. Pressure within the space can be measured when the lumbar puncture needle is inserted. Elevated pressures may will be diagnosed as idiopathic intracranial hypertension (previously known as pseudotumor cerebri) in combination with the appropriate history and physical examination.

Other tests

Depends on the specific conditions of the patients.

When to seek treatment for Headache

This is perhaps the most important question. While a simple head ache goes away with a cup of tea or an aspirin, other headaches may indicate major diseases.

The time to see a doctor or a neurosurgeon immediately is when a patient has the “worst head ache of his/her life”. This is how a case of subarachnoid haemorrhage [an emergency condition requiring immediate treatment] due to a ruptured cerebral aneurysm presents.

However, the capacity to bear pain is subjective to each individual. Many a times patients may “I am suffering from the worst head ache of my life” even for a not so serious head ache. But the following situations definitely need immediate medical attention:

  1. A head ache which is different in any way compared to the patient’s usual head aches
  2. A head ache which starts suddenly or is aggravated by exertion, coughing, bending over, or sexual activity
  3. A head ache associated with persistent nausea and vomiting
  4. A head ache associated with fever or stiff neck. This is a serious head ache as a stiff neck may be due to meningitis or blood from a ruptured aneurysm. However, many patients who complain of a stiff neck may have muscle spasm and inflammation, which are not serious conditions.
  5. A head ache associated with seizures
  6. A head ache associated with recent head injury or a fall
  7. A head ache associated with changes in vision, speech, or behaviour
  8. A head ache associated with weakness or change in sensation on one side of the body, it may be a sign of stroke
  9. A head ache not responding to treatment or if it gets worse
  10. A head ache which requires more than the recommended dose of over-the-counter medications for pain
  11. A head ache which is disabling and interferes with daily work and quality of life  

Home remedies for headache

How to get rid of headache?  It is important to remember that an unusual head ache must be evaluated by at least the family doctor, but in most instances, many headaches including primary tension head aches may be treated at home.

Here are few things you can do for headache treatment at home:
  1. Take rest and stay well hydrated.
  2. Recognize and reduce stressful situations, if those are the causes of the head ache.
  3. For a cold with nasal congestion or a runny nose, steam inhalation may be helpful.
  4. Rubbing or massaging the temples or the muscles at the back of the neck may be soothing.
  5. Warm compresses on the temples or the muscles at the back of the neck may relieve pain.
  6. Over-the-counter pain medicine for headache may be helpful, but they must be used in moderation
  7.  Message pressure points for headache

As mentioned, patients who have secondary head aches will need to seek expert medical care.