Headache causes and diagnosis in adults

Patient information: Headache causes and diagnosis in adults

Authors
Zahid H Bajwa, MD
R Joshua Wootton, MDiv, PhD
Section Editor
Jerry W Swanson, MD
Deputy Editor
John F Dashe, MD, PhD

Disclosures

HEADACHE OVERVIEW — Headaches can be quite debilitating, although most headaches are not caused by life-threatening disorders. Most headaches are caused by one of four syndromes (table 1):

Tension-type headache
Migraine headache
Chronic daily headache
Cluster headache
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
Pain 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 feel 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.

MIGRAINE HEADACHES — Migraine headaches are a type of headache that causes moderate to severe pain that is worsened by light, noise, and motion. Some people also experience nausea and vomiting. Migraine headaches typically last for a few hours, but may last for as long as three days. Migraines are discussed in detail in a separate article. (See “Patient information: Migraine headaches in adults”.)

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. Men are affected more commonly than women, with a peak age of onset of 25 to 50 years.

Symptoms — Cluster headaches:

Begin quickly without any warning and reach 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.
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, and pale skin.
Some people are light sensitive in the eye on the affected side.
Cluster headaches can begin at any age. People with cluster headaches are more likely to have family members who also have cluster headaches. Drinking alcohol can bring on a cluster headache.

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. They often start 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 can lead to “medication-overuse headaches” (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 non-prescription medication), which then causes a rebound headache as the medication wears off, causing more medication use, and so on.

Overuse of any number of pain medications can increase the risk of developing medication-overuse headaches. To avoid medication-overuse headaches, we recommend the following:

If possible, avoid butalbital combinations (Fiorinal®, Fioricet®, Esgic®) and narcotics completely.
Do not use triptans (Imitrex® and others) or aspirin/acetaminophen/caffeine combinations (Excedrin®) more than nine days per month.
Do not use NSAIDS (eg, ibuprofen, Advil, Motrin, aspirin) more than 15 days per month.
Do not take acetaminophen (eg, Tylenol®) more than two times per week.
If you have frequent headaches, you may need a preventive medication. (See “Patient information: Headache treatment in adults”.)

OTHER TYPES OF HEADACHE — There are a number of other causes of headache.

Sinus headache — Recurrent headaches related to sinus infections are uncommon. Many, if not most, people diagnosed with sinus headaches actually have migraine headaches. (See “Patient information: Migraine headaches in adults”.)

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) [1,2]. (See “Patient information: Chronic sinusitis”.)

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. (See “Concussion and mild traumatic brain injury”.)

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. A CT scan (or MRI) may be recommended in some circumstances, for example, if symptoms are unusual, 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. You should seek medical attention immediately if your headache:

Comes on suddenly, becomes severe within a few seconds or minutes, or that could be described as “the worst headache of your life”
Is severe and occurs with a fever or stiff neck
Occurs with a seizure, personality changes, confusion, or passing out
Begins quickly after strenuous exercise or minor injury
Is new and occurs with weakness, numbness, or difficulty seeing. While migraine headaches can sometimes cause these symptoms, you should be evaluated urgently the first time these symptoms appear.
If you have persistent or frequent headaches, headaches that interfere with normal activities, or your headaches become more painful, you should see 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.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Migraine headaches in adults
Patient information: Headache treatment in adults
Patient information: Headache in children
Patient information: Chronic sinusitis

Professional Level Information:

Acute treatment of migraine in adults
Basilar-type migraine
Chronic migraine
Cluster headache: Acute and preventive treatment
Cluster headache: Epidemiology, clinical features, and diagnosis
Estrogen-associated migraine
Evaluation of headache in adults
Evaluation of the adult with headache in the emergency department
Headache in pregnancy
Headache syndromes other than migraine
Headache, migraine, and stroke
Hypnic headache
Medication overuse headache: Etiology, clinical features, and diagnosis
Overview of chronic daily headache
Pathophysiology, clinical manifestations, and diagnosis of migraine in adults
Post-lumbar puncture headache
Preventive treatment of migraine in adults
Tension-type headache in adults: Acute treatment
Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis
Tension-type headache in adults: Preventive treatment
Thunderclap headache
Concussion and mild traumatic brain injury

The following organizations also provide reliable health information.

National Library of Medicine
(www.nlm.nih.gov/medlineplus/headache.html, available in Spanish)

National Institute of Neurological Disorders and Stroke
(www.ninds.nih.gov/disorders/headache/headache.htm)

American Headache Society
(www.achenet.org/resources/information_for_patients/)

REFERENCES
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.
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.
Dodick DW. Clinical practice. Chronic daily headache. N Engl J Med 2006; 354:158.
MacGregor EA, Hackshaw A. Prevalence of migraine on each day of the natural menstrual cycle. Neurology 2004; 63:351.
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.