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A headache is pain in any part of the head, including the scalp, upper neck, face, and interior of the head. Headaches are one of the most common reasons people visit a doctor. Headaches interfere with the ability to work and do daily tasks. Some people have frequent headaches. Other people hardly ever have them.
Causes
Although headaches can be painful and distressing, they are rarely due to a serious condition. Headaches can be divided into two types:
Primary headache disorders include migraine, cluster headache, and tension-type headache.
Secondary headaches may result from disorders of the brain, eyes, nose, throat, sinuses, teeth, jaws, ears, or neck or from a bodywide (systemic) disorder.
Common causes:
The two most common causes of headache are primary headaches:
Less common causes:
Less often, headaches are due to a less common primary headache disorder called cluster headache or to one of the many secondary headache disorders (see Table 1: Headaches: Some Causes and Features of Headaches ). Some secondary headache disorders are serious, particularly those that involve the brain, such as meningitis, a brain tumor, or bleeding within the brain (intracerebral hemorrhage).
Fever can cause headaches, as can many infections that do not specifically involve the brain. Such infections include Lyme disease, Rocky Mountain spotted fever, and influenza. Headaches also commonly occur when people stop consuming caffeine or stop taking pain relievers (analgesics) after using them for a long time (called medication overuse headache).
Contrary to what most people think, eye strain and high blood pressure (except for extremely high blood pressure) do not typically cause headaches.
Evaluation
Warning signs:
In people with headaches, certain characteristics are cause for concern:
When to see a doctor:
People who have any warning sign should see a doctor immediately. If a warning sign is present, headaches may be caused by a serious disorder. For example, a severe headache with a fever and a stiff neck suggests meningitis—a life-threatening infection of the fluid-filled space between the tissues covering the brain and spinal cord (meninges). A thunderclap headache may suggest a subarachnoid hemorrhage—bleeding within the meninges, which is often due to a ruptured aneurysm. Tenderness at the temple, particularly in older people who have lost weight and have muscle aches, may indicate giant cell arteritis. Headaches in people who have cancer or who have a weakened immune system (due to a disorder or drug) may be caused by meningitis or spread of cancer to the brain. Having red eyes and seeing halos around lights suggests glaucoma, which, if untreated, leads to irreversible loss of vision.
People without warning signs but with certain other symptoms require prompt evaluation within a few days to a week. These symptoms include
If people with none of the above symptoms or characteristics start having headaches that are different from any they have had before or if their usual headaches become unusually severe, they should call their doctor. Depending on their other symptoms, the doctor may advise taking an analgesic or ask them to come for an evaluation.
What the doctor does:
Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the pain and tests that may need to be done (see Table 1: Headaches: Some Causes and Features of Headaches).
Doctors ask about the characteristics of the headache: how often it occurs, how long it lasts, where the pain is, how severe is it, whether any symptoms accompany it, and how long a sudden headache takes to reach its maximum intensity. Doctors also ask what triggers the headache, what makes it worse, and what relieves it.
Risk factors for headache are identified. They include whether people take or have stopped taking certain drugs, whether they have had a spinal tap recently, and whether they have a disorder that may account for the headache. A general physical examination is done. It focuses on the head and neck and on the brain, spinal cord, and nerves (neurologic examination—see Symptoms and Diagnosis of Brain, Spinal Cord, and Nerve Disorders: Physical Examination).
A free website at http://promyhealth.org provides a questionnaire that can help people with headaches communicate with their doctor. The questionnaire asks many of the questions that headache specialists use to help diagnose the cause of headaches. People can fill out the questionnaire, print the results, and take them to their doctor. This approach can save the people and their doctor time and help guide the evaluation.
Testing:
Most people do not need testing. However, if doctors suspect a serious disorder, tests are usually done. For some suspected disorders, tests are done as soon as possible. In other cases, testing can be done within one or more days.
Magnetic resonance imaging (MRI) or computed tomography (CT) is done immediately if people have
MRI (usually) or CT is done within a day or so if people have cancer or a weakened immune system (due to a disorder or a drug). MRI or CT is done within a few days if people have certain other characteristics—for example, headaches that begin after age 50, weight loss, double vision, a new headache that is worse when the person awakens in the morning or that awakens the person from sleep, and sometimes an increase in the frequency, duration, or intensity of chronic headaches.
A spinal tap (lumbar puncture—see Symptoms and Diagnosis of Brain, Spinal Cord, and Nerve Disorders: Spinal Tap) is done immediately if acute meningitis or encephalitis (a brain infection) is suspected. Sometimes doctors do CT or MRI before the spinal tap if they think that a mass (such as a tumor, an abscess, or a hematoma) may be present. A spinal tap can be dangerous if people have such a mass. Doctors also do a spinal tap if people have a thunderclap headache (suggesting subarachnoid hemorrhage) and the results of CT or MRI are normal.
Other tests are done within hours or days, depending on the examination results and the causes that are suspected (see Table 1: Headaches: Some Causes and Features of Headaches).
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| Some Causes and Features of Headaches |
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Type or Cause
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Common Features*
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Tests
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Primary headache (not due to another disorder)
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Cluster
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A severe, piercing headache that
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Affects one side of the head and is focused around the eye
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Lasts 30 to 180 minutes
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Occurs at the same time of day
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Occurs in clusters, separated by periods of time when no headaches occur
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Is usually not worsened by light, sounds, or odors
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Is not accompanied by vomiting
Inability to lie down and restlessness (sometimes expressed by pacing)
On the same side as the pain: A runny nose, tearing, drooping of the eyelid, and sometimes swelling of the area below the eye
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Occasionally CT or MRI of the head to rule out other disorders, particularly if the headaches have developed recently or if the pattern of symptoms has changed
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Migraine
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A moderate to severe headache that
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Is typically pulsating or throbbing, usually on one side but sometimes on both sides of the head
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Lasts several hours to days
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Can occur frequently for a long time, then disappear for weeks, months, or years
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May be triggered by exertion, lack of sleep, a head injury, hunger, or certain wines and foods
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Is lessened with sleep
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May be accompanied by nausea, vomiting, and sensitivity to loud sounds, bright light, and/or odors
Often a sensation that a migraine is beginning (called a prodrome), which may include mood changes, loss of appetite, and nausea
Sometimes preceded by temporary disturbances in sensation, balance, muscle coordination, speech, or vision, such as seeing flashing lights and having blind spots (these symptoms are called the aura)
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Same as those for cluster headaches
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Tension-type
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Usually a mild to moderate headache that
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Feels like tightening of a band around the head
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Affects the whole head
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Lasts 30 minutes to several days
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May be worse at the end of the day
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Is not worsened by physical activity, light, sounds, or odors
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Is not accompanied by nausea, vomiting, or any other symptoms
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Same as those for cluster headaches
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Secondary headache (due to another disorder)
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Altitude illness
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Light-headedness, loss of appetite, nausea and vomiting, fatigue, weakness, irritability, or difficulty sleeping
In people who have recently gone to a high altitude (including flying 6 hours or more in an airplane)
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A doctor's examination
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Brain tumor, abscess, or another mass in the brain, such as a hematoma (an accumulation of blood)
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A mild to severe headache that
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May become progressively worse
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Worsens when a person lies down and may awaken a person from sleep
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Usually recurs more and more often and eventually becomes constant without relief
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May result in blurred vision when a person suddenly changes position
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May be accompanied by clumsiness, weakness, confusion, nausea, vomiting, seizures, or impaired vision
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MRI or CT
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Carbon monoxide exposure (during winter, people may breathe this gas if heating equipment is not adequately vented)
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Possibly no awareness of the exposure because carbon monoxide is colorless and odorless
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A blood test
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Dental infections (in upper teeth)
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Pain that is
Toothache
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Dental examination
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Encephalitis (infection of the brain)
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Headaches with varying characteristics
Often accompanied by fever, worsening drowsiness, confusion, agitation, weakness, and/or clumsiness
Seizures and coma
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MRI or CT and a spinal tap
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Giant cell (temporal) arteritis
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A throbbing pain felt on one side of the head at the temple
Pain when combing the hair or while chewing
Sometimes enlarged arteries in the temples (temporal arteries) and aches and pains, particularly in the shoulders, thighs, and hips
Possibly impaired vision or loss of vision
More common among people over 60
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A blood test to measure the erythrocyte sedimentation rate (ESR), which can detect inflammation
Biopsy of the temporal artery
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Glaucoma—a type called closed-angle glaucoma—that starts abruptly (acute)
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Moderate or severe pain that
Red eyes, halos seen around lights, nausea, and loss of vision
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An eye examination as soon as possible
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Head injury (postconcussion syndrome)
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Headache that begins immediately or shortly after a head injury (with or without loss of consciousness)
Sometimes a faulty memory, personality changes, or both
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CT or MRI with normal results
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Idiopathic intracranial hypertension (increased pressure within the skull without any evidence of a cause)
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Headaches that
Sometimes nausea or ringing in the ears that occurs in time with the pulse
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MRI and magnetic resonance venography, followed by a spinal tap
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Intracerebral hemorrhage
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Mild or severe pain that
Possibly severe drowsiness, clumsiness, weakness, difficulty speaking or understanding speech, loss of vision, loss of sensation, or confusion
Occasionally seizures or coma
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CT or MRI
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Medication overuse headache
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Chronic and often daily headaches
Often in people who have migraine or tension-type headaches
Overuse of pain relievers (analgesics such as NSAIDs or opioids), barbiturates, caffeine, or sometimes triptans or other drugs to treat headaches
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A doctor's examination
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Meningitis
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A severe, constant headache
Fever
Neck stiffness that makes lowering the chin to the chest painful and sometimes impossible
A feeling of illness, drowsiness, nausea, or vomiting
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A spinal tap (often preceded by CT)
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Obstructive sleep apnea
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Headaches that occur in the morning
Snoring with episodes of gasping or choking, typically after pauses in breathing during sleep
Daytime sleepiness
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A doctor's examination
Sleep laboratory evaluation with polysomnography
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Sinusitis
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Pain that
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Is sometimes felt in the face, at the front of the head, or as tooth pain
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May begin suddenly and last only days or hours or begin gradually and be persistent
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Is worse when facing the floor
A runny nose, sometimes with pus or blood
A feeling of illness, possibly a cough at night, and often a fever
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Possibly CT of the sinuses or endoscopy of the nose
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Subarachnoid hemorrhage (bleeding between the inner and middle layers of tissues covering the brain)
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Severe, constant pain that
Possibly brief loss of consciousness as the headache begins
Possibly drowsiness, confusion, difficulty being aroused, or coma
A stiff neck, nausea and vomiting, dizziness, and low back pain
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MRI or CT
If MRI or CT results are negative or inconclusive, a spinal tap
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Subdural hematoma (a pocket of blood between the outer and middle layers of tissues covering the brain)
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Headaches with varying characteristics
Possibly sleepiness, confusion, forgetfulness, and/or weakness or paralysis on one side of the body
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MRI or CT
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Temporomandibular disorders
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Pain when chewing hard foods
Sometimes pain in or around the jaw or in the neck
Sometimes clicking or popping when the mouth is opened, locking of the jaw, or difficulty opening the mouth wide
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Physical examination
Occasionally MRI, x-rays, or CT
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*Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.
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CT = computed tomography; MRI = magnetic resonance imaging; NSAIDs = nonsteroidal anti-inflammatory drugs.
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Treatment
Treatment depends on the cause. If the headache is a tension headache or if it accompanies a minor viral infection, people can take acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID—see Pain: Nonsteroidal Anti-Inflammatory Drugs).
Essentials for Older People
If headaches begin after age 50, doctors usually assume they result from another disorder until proved otherwise. Disorders that cause headaches, such as giant cell arteritis, brain tumors, and subdural hematomas (which may result from falls), are more common among older people.
Treatment of headaches may be limited in older people. They are more likely to have disorders that prevent them from taking some of the drugs used to treat migraines and cluster headaches (triptans and dihydroergotamine—see Headaches: Drugs Used to Treat Migraines). These disorders include angina, coronary artery disease, and uncontrolled high blood pressure. If older people need to take drugs to treat headaches that can have sedating effects, they must be monitored closely.
Key Points
Last full review/revision May 2012 by Stephen D. Silberstein, MD
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