Headache – FAQs

Headache is defined as pain in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck.

• Primary headaches which are not associated with other diseases. Examples are migraine headaches, tension headaches, and cluster headaches.
• Secondary headaches are caused by associated disease. The associated disease may be minor or serious and life threatening.

• Tension headaches are the most common type and are more common among women than men.
• Migraine headaches are the second most common type of primary headache which affect children as well as adults. Before puberty, boys and girls are affected equally but after puberty, more women than men are affected.
• Cluster headaches are a rare type and affect men more commonly.
• Secondary headaches have diverse causes, ranging from serious and life threatening conditions such as brain tumors, strokes, meningitis, and subarachnoid hemorrhages to less serious but common conditions such as withdrawal from caffeine and discontinuation of analgesics.

Tension headaches often begin in the back of the head and upper neck as a band-like tightness or pressure with the most intense pain over the eyebrows which are seldom associated with nausea, vomiting, or sensitivity to light and sound. Tension headaches usually occur sporadically (infrequently and without a pattern).

Migraine is a chronic condition of recurrent attacks. Most (but not all) migraine attacks are associated with headache which is intense, throbbing or pounding pain that involves one temple. (Sometimes the pain can be located in the forehead, around the eye, or the back of the head). The pain usually is unilateral (on one side of the head. Nausea, omiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.

Cluster headaches are headaches that come in groups (clusters) lasting weeks or months, separated by pain-free periods of months or years. During the period in which the cluster headaches occur, pain typically occurs once or twice daily.Each episode of pain lasts from 30 minutes to one and one-half hours. Attacks tend to occur at about the same time every day and often awaken the patient at night from a sound sleep. The pain typically is excruciating and located unilaterally around or behind one eye. The affected eye may become red, inflamed, and watery. The nose on the affected side may become congested and runny. Such patients with tend to be restless.

• Migraine headache is caused by a combination of vasodilatation (enlargement of blood vessels) and the release of chemicals from nerve fibers that coil around the blood vessels. The chemicals cause inflammation, pain, and further enlargement of the temporal artery. The increasing enlargement of the artery magnifies the pain.
• Tension headache does not have a clear cause. Many physicians attribute tension headaches to excess stress or a hectic day
• Cluster headache also does not have a clear cause, although alcohol and cigarettes can precipitate attacks.

• Tumors in the brain, including tumors that have spread (metastasized) to the brain from another organ such as the lung or breast
• Subdural hematomas, which are collections of blood underneath the dura (the covering of the brain) due to bleeding from ruptured veins after a fall or other trauma to the head.
• Epidural hematomas, which are rapid collections of blood due to the rupture of arteries that run on the inner surface of the skull and are the result of skull fractures
• Infections such as meningitis caused by bacteria (meningococcus and pneumococcus), tuberculosis, Lyme disease, or Cryptococcus
• Strokes either due to blood clots within the arteries of the brain or rupture of the blood vessels in the brain
• Subarachnoid hemorrhages which are caused by bleeding into the space between the brain and its outer arachnoid lining.
• Sudden onset of severe high blood pressure
• Temporal arteritis, a vasculitis (inflammation) of the temporal artery which runs beneath the skin of the temple. Without proper treatment, temporal arteritis may lead to blindness and strokes.
• Acute angle glaucoma with sudden elevation of pressures inside the eyes
• Infections of the sinuses (sinusitis), ear (otitis), and teeth
• Hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormone
• Repeated carbon monoxide poisoning
• Parkinson’s disease
• Medications such as indomethacin, estrogen, progestins, calcium channel blockers (commonly used for treating high blood pressure), and selective serotonin reuptake inhibitors (commonly used to treat depression)
• Overuse of over-the-counter or prescription pain relievers which cause headaches to recur (rebound headache).
• Cardiac ischemia (lack of blood supply to the muscles of the heart caused by coronary artery disease.The headache may occur with or without the accompanying chest pain of a heart attack or angina. As with angina, in some individuals the headache may occur with exertion and subside with rest.

Conditions causing secondary headaches can cause serious brain damage or even death. Therefore, timely and accurate diagnosis of secondary headaches is crucial. Special blood tests, brain scans, CT scans or MRI, and lumbar puncture (spinal tap) are necessary to establish these diagnoses. The doctors rely upon information obtained from the initial patient interview and physical examination:

The mode of onset of the headache, the age of the patient, the location of the headache, associated fever and neck stiffness ,associated mental deterioration, seizures, or weakness of the extremities or face or any recent head trauma.

Many people who suffer from mild headaches medicate themselves with over-thecounter analgesics, and they usually do not seek medical care. But the alarming signals to consult a doctor are:

• Severe (“the worst ever”)
• Different than the usual headaches
• Starts suddenly during exertion
• Aggravated by exertion, coughing, bending, or sexual activity
• Associated with persistent nausea and vomiting
• Associated with stiff neck, fever, dizziness, blurred vision, slurred speech, unsteady gait, weakness or unusual sensations of the arm or leg, excessive drowsiness or confusion
• Associated with seizures
• Associated with recent head trauma or a fall
• Not responding to treatment and is getting worse
• Disabling, and interfering with work and the quality of life
• Requires more than the recommended dose of over-the-counter analgesics for relief

Individuals with occasional tension headaches or mild migraine headaches that do not interfere with daily activities usually medicate themselves with over-the-counter (OTC, non-prescription) pain relievers (analgesics) like non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen etc. NSAIDs relieve pain by reducing the inflammation that causes the pain and they are different from corticosteroids such as prednisone, in that, NSAIDs do not have the same side effects that corticosteroids have. Finding an effective analgesic or analgesic combination often is a process of trial and error because individuals respond differently to different analgesics. In general, a person should use the analgesic that has worked in the past. This will increase the likelihood that an analgesic will be effective and decrease the risk of side effects.

There are several precautions that should be observed with OTC analgesics:

• Children and teenagers should not use aspirin for the treatment of headaches, other pain, or fever, because of the risk of developing Reye’s syndrome, a lifethreatening neurological disease that can lead to coma and even death.
• Patients with balance disorders or hearing difficulties should avoid using aspirin because aspirin may aggravate these conditions.
• Patients taking blood thinners such as warfarin (Coumadin) should not take aspirin and non-aspirin NSAIDs without a doctor’s supervision because they add further to the risk of bleeding that is caused by the blood thinner.
• Patients with active ulcers of the stomach and duodenum should not take aspirin and non-aspirin NSAIDs because they can increase the risk of bleeding from the ulcer and impair healing of the ulcer.
• Patients with advanced liver disease should not take aspirin and non-aspirin NSAIDs because they may impair kidney function. Deterioration of kidney function in these patients can lead to rapid and life-threatening deterioration of their liver disease.
• Patients should not overuse OTC or prescription analgesics. Overuse of analgesics can lead to the development of tolerance (increasing ineffectiveness of the analgesic) and rebound headaches (return of the headache as soon as the effect of the analgesic wears off, usually in the early morning hours).

There are two approaches to treat cluster headaches: abortive and prophylactic. Abortive treatment is taken to stop the headaches. Prophylactic treatment is used to abolish or shorten the cycle of headaches.

Abortive treatments include inhalation of 100% oxygen at 8-10 liters/minute using a non-rebreathing facemask for 10-15 minutes along with a triptan such as sumatriptan (nasally, or under the skin) or an ergot such as DHE (intravenously, under the skin, or intramuscularly).

A calcium channel blocker, verapamil is the medication of choice for prophylactic treatment of cluster headaches. Other prophylactic medications include valproate, ergotamine, lithium, and methysergide. Prophylactic medications usually are begun early during a cycle of cluster headaches and continued for two weeks longer than the usual cycle. The dose of medication then is reduced gradually.