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.
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.
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 see Table 1: 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.
The following information can help people decide when a doctor's evaluation is needed and help them know what to expect during the evaluation.
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: 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 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.
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 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: Some Causes and Features of Headaches).
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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 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 Table: 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.
Last full review/revision May 2012 by Stephen D. Silberstein, MD