When Should I Worry about a Headache?
If you experience a severe headache or migraine, it’s difficult to believe so much pain isn’t doing lasting damage. Most often, it really isn’t. There are only a few rare types of headache that can be cause for worry (see Dangerous Types of Headache).
If you experience any of the following symptoms for the first time with a headache, seek medical advice:
- Loss of vision
- Paralysis in any part of your body
- Stiff neck
- The worst headache you’ve ever had
- Slurred speech
- Temperature of 100.4°F (38°C) or higher.
Although some of these symptoms are typical of certain Benign or Primary Headaches, they are also warning signs of other health problems, so see a doctor without delay.
Types of Headache: Benign or Primary
A primary headache is a type of headache when the headache itself is the condition and it isn’t a sign or side effect of something else. When you’re in the throes of one, it’s hard to believe, but medically, it’s benign. Primary headaches include Migraine, Cluster Headache, Tension Type Headache and several rarer types.
Migraine is very common and extremely disabling. It is episodic (occasional) or chronic (15 or more days per month) with or without aura (specific neurological warning signs, often visual, before the migraine begins, such as seeing geometric patterns or flashing lights. Tingling sensations or difficulty with speech are also possible). It often includes a prodrome, a period preceding the migraine when general symptoms warn of impending arrival. These might include yawning, food cravings and irritability. During the migraine attack, head pain, although not always present, can be extreme, and is often one-sided and throbbing. There may also be nausea and vomiting, sensitivity to light, sound or touch and malaise. A postdrome phase may follow and is often similar to a hangover.
When experiencing migraine for the first time, see a doctor to rule out any underlying health issues. Once diagnosed, migraine is categorized as a Benign or Primary Headache and not dangerous.
That said, people who have migraine with aura are twice as likely to have a stroke in later life than those without. If you’re an older person with migraine, watch out for any symptoms of stroke, and phone emergency services without delay if they’re experienced.
Children are more likely to experience abdominal migraine, although some adults may do so too. This is usually felt as frequent bouts of tummy ache in children who have a family history of migraine, when no other cause for the pain can be found.
Some chronic types of migraine have been aggravated by overly frequent use of headache drugs, resulting in Medicine Overuse Headache (MOH), also known as Rebound Headache. In these cases, it’s important to stop those drugs to break the cycle. Use preventive medicines to avoid the need for frequent use of painkillers. Caffeine can also frequently cause rebound headaches.
Chronic Daily Headache
Chronic Daily headache affects 4% of adults, especially snorers and high-caffeine users. Symptoms are headache lasting more than four hours on more than 15 days a month. Some people experience these headaches for a period of six months or longer. The term is sometimes used interchangeably with Medicine Overuse Headache, but it may be used to refer specifically to daily headaches in the absence of any overuse of caffeine or medicines. There are several other types of daily headache, including New Daily Persistent Headache, Status Migrainosus and Hemicrania Continua.
Tension Type Headache
Tension Type Headache involves mild to moderate head pain that feels like a tight band around the head or a weight on top of it. Movement does not make it worse. The neck or shoulder muscles may also hurt along with the headache. These headaches can trigger migraine or become chronic. Exercise, massage and yoga can be useful, in addition to minimizing the source of the tension. Tooth grinding or jaw clenching (bruxism) may aggravate the problem, especially if you wake up regularly with a tension-type headache. A dental splint may help.
Cluster headache is a recurrent, extreme, one-sided headache. It often centers on one eye or temple and reaches full intensity within 5 to 10 minutes and typically lasts at this intense level for 30-60 minutes, although 3 hours has been known. It then stops, usually quite abruptly, but then recurs at a similar time each day, often at night, waking people 1-2 hours after they’ve gone to sleep. Cluster attacks may happen every other day, or up to 8 times daily during a bad cluster.
Most people have episodic clusters lasting 4-12 weeks once a year, often at the same season, in Spring or Autumn. They may then disappear for several months or even years. They can, however, be chronic. They’re more common in men and heavy smokers.
Treatment requires a speedy delivery because of the rapid onset of pain. Use nasal or injected triptans and/or high-flow oxygen (and anecdotally, psilocybin, although it is illegal in most countries), as well as preventives.
Chronic Paroxysmal Hemicrania
This type of headache is very similar to Cluster Headache but differs in that attacks are more frequent but of shorter duration. It isn’t suffered mostly by men. It isn’t mostly at night and responds well to Indomethacin.
Cyclical Vomiting Syndrome
Migraine in children more often manifests as tummy pain than headache. As well as Abdominal migraine, young children may have recurrent episodes of vomiting lasting for several hours or days, with all the features of migraine except headache. Cyclical vomiting syndrome attacks often occur with predictable regularity, every 2-8 weeks and last for an average of 24 hours, but longer attacks are not uncommon. The child vomits several times an hour, is lethargic and may get dehydrated and complain of abdominal pain or headache, and light, noise or smell intolerance. The attacks resolve spontaneously after up to three days, after which the child wants to lie down and sleep. Between attacks the child returns to normal. Preventives plus anti-emetics may be prescribed.
A rare headache that responds completely to treatment! Hemicrania Continua is a chronic daily headache where underlying organic causes have been ruled out. It usually occurs in women, and is characterized by a continuous, fluctuating, unilateral (on one side only) head pain that doesn’t shift sides, unlike in New Daily Persistent Headache.
Pain can last from 20 minutes to several days, with perhaps watery or red eyes, blocked or runny nose, and eyelid drooping on the same side as the pain. Migrainous symptoms, such as light or sound sensitivity, nausea and vomiting are also present. The condition is usually continuous, but some patients have an episodic or remitting form with distinct headache phases separated by pain-free periods.
The good news is that it’s 100% responsive to Indomethacin. The positive response to this drug is an essential criterion for the diagnosis.
Menstrual Migraine or Hormone Headaches
Menstrual migraine is associated with changing levels of hormones, especially during early pregnancy, the approach of the menopause, with menstruation, with drugs such as the contraceptive pills and hormone replacement therapy. It affects less than 10% of women. Possible treatments to discuss with the doctor include mefenamic acid, triptans and oestrogen supplements.
Headaches experienced during exercise can be minimized by extending the warm-up routine or reducing the intensity of exercise. The following symptoms need investigation because there’s a small chance of a circulatory issue, such as cardiac cephalalgia:
- Headache on both sides of the back of the head
- Chest/neck/arm discomfort
- Shortness of breath
- Light headedness
- Nausea and sweating
- But no aura, or light sensitivity.
Avoid triptans in case of heart issues.
Sex headaches are painful headaches experienced when sexually aroused. They’re more common in men. The pain can be mild to severe, a dull ache, throbbing or explosive. It is on both sides of the head; most often, in the back of the head or the top of the neck. Severe pain may last from 1 minute to 1 day; milder headaches may last up to 3 days.
See a doctor to rule out conditions such as brain haemorrhage or a tear in the arteries in the head or neck.
If the headache begins after sex, gets worse when standing, and then better when lying down again, the cause may be low-pressure headaches due to leaking spinal fluid.
Treatment for sex headaches may include Indomethacin, triptans or beta-blockers.
Migraine with Brainstem Aura/Basilar Migraine
This is a rare subtype of migraine with aura, which can be mistaken for stroke. It occurs mostly in young people. Although similar to Hemiplegic Migraine, symptoms are on both sides of the body and include two or more of the following:
- Slurred speech
- Double vision
- Unsteady gait
- Transient impairment of consciousness (syncope)
- Simultaneous bilateral sensory symptoms e.g. pins and needles and/or numbness affecting both arms and/or legs
- Simultaneous bilateral visual aura.
New Daily Persistent Headache
A rare type of headache that starts one day and never stops in people who aren’t prone to migraine. It’s like a Tension Type Headache that is bilateral and of mild to moderate severity.
It’s easily confused with Hemicrania Continua but while hemicrania continua is always present on one side only and responds to Indomethacin, New Daily Persistent Headache can be all over the head and Indomethacin is ineffective. Treatment is with tricyclic antidepressants, and possibly CGRP monoclonal antibodies. See Status Migrainosus.
In ocular or retinal migraine, occasional bouts of short-lived vision problems or blindness occur in one eye only, often accompanied or followed by headache. By contrast, in migraine with a visual aura, the aura is seen with both eyes. It may be caused by interrupted blood flow and damage to the retina is a rare complication.
The sinuses are hollow spaces within the skull, including behind the eyes and nose that can, rarely, become infected, blocked and painful. The pain can be gnawing, becoming intense as the day progresses and there may be fever. Migraine and cluster headache are commonly misdiagnosed or self-diagnosed as a sinus infection. However, sinus headaches may sometimes be caused by allergies, so it’s worth getting a proper diagnosis since the treatment for an infection is quite different from that for an allergy, or migraine.
Vestibular Migraine is a combination of vertigo, dizziness or balance problems with other migraine symptoms lasting between five minutes and 72 hours. Some people have vertigo attacks without any headache but there must be some migraine symptoms.
See an ENT doctor to rule out vestibular disorders. Treatments include preventives, Flunarizine and Prochlorperazine.
See a doctor urgently if you have a new type of headache, especially if it’s accompanied by seizures, persistent nausea, drowsiness, personality changes or memory problems, vision or speech problems or any weakness or paralysis, and especially if it fits the description of Thunderclap Headache or Temporal Arteritis/Giant Cell Arteritis.
Thunderclap headache, like its name, is sudden and tremendous, reaching maximum intensity in one minute and lasting at least five minutes.
Some thunderclap headaches are benign, primary headaches, i.e. they have no obvious cause, in which case Indomethacin or a calcium channel blocker, like Nimodipine, can be tried.
However, they can be a symptom for subarachnoid haemorrhage, where an aneurysm ruptures into the cerebrospinal fluid, so seek emergency medical attention for a thunderclap headache.
Temporal Arteritis/Giant Cell Arteritis
An autoimmune disease involving inflammation of the temporal arteries. You may notice sensitivity or pain in the scalp or temples and see angry bulging arteries in the temples, with or without headache. The jaw may also be painful when chewing. Temporal arteritis is a medical emergency and must be treated without delay since the arteries can block blood flow to the optic nerve and cause irreversible blindness. Treatment is with corticosteroids.
Types of Headache: Potentially Dangerous
This headache can be confused with a stroke. There is temporary weakness on one side of the body, either the face, arm or leg; numbness, or pins and needles; speech difficulties, vision problems or confusion. This weakness may last from one hour to several days, but usually it goes within 24 hours. The head pain associated with migraine typically follows the weakness, but the headache may precede it or be absent. It’s useful to know that symptoms of a stroke are sudden whereas those of hemiplegic migraine can take several seconds or minutes to develop. Hemiplegic migraine can run in families. Often prescribed: Flunarizine or Topiramate. Avoid triptans.
High Altitude Headache/Mountain Sickness
The principal symptom of acute mountain sickness is moderate or severe headache when ascending more than 500 meters per day, combined with one or more other symptoms including:
- Anorexia (loss of appetite)
- Sleep disturbances
Slow ascent and plenty of fluids can help avoid it. If not severe, it resolves within eight hours of descent. But it can progress to a dangerous buildup of fluid in the lungs (High Altitude Pulmonary Edema — HAPE); or a swelling of the brain (High Altitude Cerebral Edema — HACE) characterized by:
- Incapacitating fatigue
- Chest tightness
- Shortness of breath, with minimal effort, that develops to shortness of breath at rest and even when lying flat
- Dry cough
Anyone suffering from worsening symptoms of HACE or HAPE must descend immediately and be evacuated to a medical facility for treatment.
Hypnic headaches or alarm clock headaches are rare, and occur exclusively at night, usually 1-3am with unilateral or bilateral head pain, often throbbing. The pain begins abruptly and can last from 15 minutes to 6 hours, although typically it is about 30-60 minutes. It’s more common among women than men, typically age 50+. Sometimes blocked nose or watering eyes, light or sound sensitivity may co-occur.
Things to rule out with these headaches include drug withdrawal, sleep apnoea, brain tumors and Temporal/Giant Cell Arteritis. Treatments include caffeine and Indomethacin. Because these types of headache are related to the body clock, lithium and melatonin may be helpful.
Low Pressure Headache
Cerebrospinal Fluid leaks can cause spinal fluid pressure to drop, allowing the brain to sag inside the skull, causing migraine-like headaches that worsen when the patient is in an upright position (sitting or standing up) and improve when lying down. Leaks can occur after surgeries, spinal taps and as a result of nerve root cysts. They are more common in people with hypermobile joints or with Ehlers Danlos Syndrome. Spontaneous leaks may also arise from bone spurs along the spine. Treat with injected fluids or an epidural patch.
Rarely, stretching nerves or the downward displacement of the brain cause more serious neurological symptoms.
High Pressure Headache
High pressure headache is a condition that apparently results from a spinal fluid absorption problem, rather than from the brain making too much spinal fluid. Spinal fluid is not properly absorbed, resulting in increased pressure. It usually affects women of reproductive age, often who are overweight or have recently gained weight. Other things that can lead to high-pressure headache include various antibiotics and medicines, wheat, coming off corticosteroids, growth hormone replacement drugs and vitamin A derivatives.
Current treatments for Increased Intercranial Hypertension include weight reduction, medical treatment, CSF diversion surgery, optic nerve sheath fenestration and, potentially, endovascular stenting. Prompt treatment is important to prevent loss of vision, which can be permanent.
Symptoms of chronic intracranial hypertension can include:
- A constant throbbing headache, often worse in the morning, or when coughing or straining that may improve when standing
- Temporary loss of vision perhaps when coughing, sneezing or bending down. Vision may become dark or greyed out for a few seconds at a time.
- Feeling sleepy or irritable
Primary Cough Headache/Valsalva Headache
Primary Cough or Valsalva Headache is very short-lived headache, usually less than 30 minutes or sometimes just seconds, triggered when coughing, sneezing or blowing the nose. These actions cause increased pressure in the blood vessels around the head.
Treatments include Diamox to lower intracranial pressure or Indomethacin.
There are a number of secondary headaches that may mimic a primary cough headache and some are life-threatening, so medical advice should be sought.
This is a severe migraine that lasts more than 72 hours. Due to its relentless and never-ending nature it can be an emergency medical situation. If untreated, it can lead to dehydration and, in the long-term, to psychological issues such as anxiety and depression, which increases the risk of suicide.
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