Overview of Headache
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
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Cluster headache and other trigeminal autonomic cephalgias, including chronic paroxysmal hemicrania, hemicrania continua, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)
Trigeminal autonomic cephalgias are rare.
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
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 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
Doctors focus on the following:
If no cause is identified, they focus on identifying which type of primary headache is present.
Warning signs
In people with headaches, certain characteristics are cause for concern:
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Changes in sensation or vision, sudden weakness, loss of coordination, seizures, difficulty speaking or understanding speech, or changes in levels of consciousness such as drowsiness or confusion (suggesting a brain disorder)
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A fever and a stiff neck that makes lowering the chin to the chest painful and sometimes impossible
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A very sudden, severe headache (thunderclap headache)
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Tenderness at the temple (as when combing hair) or jaw pain when chewing
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The presence of cancer or a disorder that weakens the immune system (immunodeficiency disorder), such as AIDS
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Use of a drug that suppresses the immune system (immunosuppressant)
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Symptoms that affect the whole body such as fever or weight loss
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A headache that progressively worsens (in frequency or severity)
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Red eyes and halos seen around lights
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Very high blood pressure
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Headaches that begin after age 50
When to see a doctor
People who have any warning sign should see a doctor immediately. The presence of a warning sign may suggest that the headaches may be caused by a serious disorder, as for the following:
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A severe headache with a fever and a stiff neck: Meningitis—a life-threatening infection of the fluid-filled space between the tissues covering the brain and spinal cord (meninges)
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A thunderclap headache: A subarachnoid hemorrhage (bleeding within the meninges), which is often due to a ruptured aneurysm
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Tenderness at the temple, particularly in older people who have lost weight and have muscle aches: Giant cell arteritis
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Headaches in people who have cancer or a weakened immune system (due to a disorder or drug): Meningitis or spread of cancer to the brain
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Red eyes and halos seen around lights: Glaucoma, which, if untreated, leads to irreversible loss of vision
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 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 Some Causes and Features of Headaches).
Doctors ask about the characteristics of the headache:
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How often it occurs
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How long it lasts
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Where the pain is
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How severe is it
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What the pain is like (for example, whether it is throbbing, dull, or like a knife)
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Whether any symptoms accompany it
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How long a sudden headache takes to reach its maximum intensity
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What triggers the headache, what makes it worse, and what relieves it
Other questions may include
Doctors also ask about risk factors for headache. They include
People can think about how to answer the above questions and write the answers down before they go to the doctor. Doing so can save time and help guide the evaluation.
A general physical examination is done. It focuses on the head and neck and on brain, spinal cord, and nerve function (neurologic examination). An eye examination is sometimes also done.
Testing
Most people do not need testing. However, if doctors suspect a serious disorder, tests are 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 as soon as possible if people have
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A thunderclap headache
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Changes in levels of consciousness, such as drowsiness or confusion
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A fever and a stiff neck that makes lowering the chin to the chest painful and sometimes impossible
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Swelling of the optic nerve (papilledema), detected by eye examination with an ophthalmoscope
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Symptoms that suggest a serious bodywide response to an infection (sepsis), such as a certain type of rash or shock
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Symptoms that suggest a brain disorder, such as changes in sensation or vision (including double vision), sudden weakness, loss of coordination, seizures, or difficulty speaking or understanding speech
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Extremely high blood pressure
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A head injury causing headache and loss of consciousness
MRI (usually) or CT is done within a day or so if people have conditions such as the following:
MRI or CT is done within a few days if people have certain other characteristics, such as the following:
A spinal tap (lumbar puncture) is usually done if
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Acute meningitis or encephalitis (a brain infection) is suspected.
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People have a thunderclap headache (suggesting subarachnoid hemorrhage) even when the results of CT or MRI are normal.
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People have a weakened immune system.
Usually, doctors do CT or MRI before the spinal tap if they think that pressure within the skull may be increased—for example, by a mass (such as a tumor, an abscess, or a hematoma). A spinal tap can be dangerous if pressure within the skull is increased. When spinal fluid is removed and pressure within the skull is increased, parts of the brain may suddenly shift downward. If these parts are pressed through the small openings in the tissues that separate the brain into compartments, a life-threatening disorder called brain herniation results.
Other tests are done within hours or days, depending on the examination results and the causes that are suspected.
Some Causes and Features of Headaches
Type or Cause |
Common Features* |
Tests |
Primary headache (not due to another disorder) |
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A severe, piercing headache that
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 (Horner syndrome), and sometimes swelling of the area below the eye |
A doctor's examination Occasionally MRI or CT 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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A moderate to severe headache that
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) |
Same as those for cluster headaches |
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Usually a mild to moderate headache that
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Same as those for cluster headaches |
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Secondary headache (due to another disorder) |
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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) |
A doctor's examination |
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Blood clots in a large vein that drains blood from the brain (cerebral venous sinus thrombosis) |
Headaches that Sometimes double or blurred vision, nausea, or ringing in the ears that occurs in time with the pulse (pulsatile tinnitus) Sometimes seizures and symptoms similar to those of a stroke (such as paralysis of an arm or leg and loss of vision) |
MRI and magnetic resonance venography |
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Brain tumor, abscess, or another mass in the brain, such as a hematoma (an accumulation of blood) |
A mild to severe headache that
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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) |
Possibly no awareness of the exposure because carbon monoxide is colorless and odorless |
A blood test |
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Dental infections (in upper teeth) |
Pain that is Toothache |
Dental examination |
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Encephalitis (infection of the brain) |
Headaches with varying characteristics Often accompanied by fever, worsening drowsiness, confusion, agitation, weakness, and/or clumsiness Seizures and coma |
MRI or CT and a spinal tap |
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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 tender, 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 55 |
A blood test to measure the erythrocyte sedimentation rate (ESR), which can detect inflammation Biopsy of the temporal artery Imaging such as MRI or magnetic resonance angiography (MRA) |
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Glaucoma—a type called closed-angle glaucoma—that starts abruptly (acute) |
Moderate or severe pain that occurs at the front of the head or in or over an eye Red eyes, halos seen around lights, nausea, vomiting, and loss of vision |
An eye examination as soon as possible |
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Head injury (postconcussion syndrome) |
Headache that begins immediately or shortly after a head injury (with or without loss of consciousness) Sometimes a faulty memory, personality changes, or both |
CT or MRI |
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Idiopathic intracranial hypertension (increased pressure within the skull without any evidence of a cause) |
Headaches that Sometimes double or blurred vision, nausea, or ringing in the ears that occurs in time with the pulse (pulsatile tinnitus) |
MRI and magnetic resonance venography, followed by a spinal tap |
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Intracerebral hemorrhage (bleeding within the brain) |
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 |
CT or MRI |
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Low-pressure headache (which occurs when cerebrospinal fluid† is removed or leaks out) |
Intense headaches, often accompanied by a stiff neck and nausea Pain that worsens when sitting or standing and that is relieved by lying flat Usually occurs after a spinal tap (lumbar puncture) |
A doctor's examination If the headache develops on its own (not after a spinal tap), MRI after a contrast agent is injected into a vein |
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Chronic and often daily headaches that vary in location and intensity Often present when the person awakens in the morning 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 |
A doctor's examination |
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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 |
A spinal tap (usually preceded by CT) |
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Pain that A runny nose, sometimes with pus or blood A feeling of illness, possibly a cough at night, and often a fever |
A doctor's examination 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) |
Severe, constant pain that Possibly brief loss of consciousness as the headache begins Possibly drowsiness, confusion, difficulty being aroused, or coma A stiff neck and nausea and vomiting |
MRI or CT If MRI or CT results are negative, a spinal tap |
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Subdural hematoma (a pocket of blood between the outer and middle layers of tissues covering the brain) |
Headaches with varying characteristics Possibly sleepiness, confusion, forgetfulness, and/or weakness or paralysis on one side of the body More common among older people and people who have dementia or who take anticoagulants‡ or abuse alcohol |
MRI or CT |
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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 |
Physical examination, sometimes by a dentist Occasionally MRI, x-rays, or CT |
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Trigeminal neuralgia |
Repeated short, lightning-like bursts of pain in the middle and lower half of one side of the face |
A doctor's examination |
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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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† Cerebrospinal fluid is the fluid that surrounds the brain and spinal cord and helps cushion and support them. |
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‡ Anticoagulants are drugs that prevent blood from clotting or slow the clotting process. |
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CT = computed tomography; MRI = magnetic resonance imaging; NSAIDs = nonsteroidal anti-inflammatory drugs. |
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Treatment
Treatment of headache 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).
Essentials for Older People
If headaches begin after age 50, doctors usually assume they result from another disorder until proved otherwise. Many 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. Older people 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 Some 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 make them feel drowsy, they must be monitored closely.
Key Points
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Most headaches do not have a serious cause, particularly if the headaches began at a young age, if they have not changed over time, and if results of the examination are normal.
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If headaches occur frequently or if warning signs are present, people should see a doctor.
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Most headaches do not require testing.
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Doctors can usually determine the type or cause of headaches based on the medical history, symptoms, and results of a physical examination.
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If doctors suspect that the cause is a serious disorder (such as a hemorrhage or an infection), CT or MRI is usually done, often immediately.
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If doctors suspect meningitis, encephalitis, or a subarachnoid hemorrhage, a spinal tap is done.
