Headache Disorders

Headache disorders originate in the nervous system. They are one of the most common disorders, and are sometimes associated with other conditions.

Migraine is a type of headache characterized by recurrent attacks of moderate to severe throbbing and pulsating pain on one side of the head. The pain is caused by the activation of nerve fibers within the wall of brain blood vessels traveling inside the meninges (three layers of membranes protecting the brain and spinal cord).

Recurrent headaches are a sign of a headache disorder. Types of disorders besides migraine include tension headaches and trigeminal autonomic cephalgias (cluster headaches).

Headaches affect people of all ages, races and socioeconomic status and are more common in women. Some headaches are extremely debilitating and have a significant impact on an individual’s quality of life, imposing huge costs to healthcare and indirectly to the economy in general. Only a small proportion of headache disorders require specialist input. The vast majority can be effectively treated by a primary care physician or generalist with correct clinical diagnosis that requires no special investigation. 

Tension-type headache is the most common type of headache. Its name indicates the role of stress and mental or emotional conflict in triggering the pain and contracting muscles in the neck, face, scalp and jaw. 

The most severe form of primary headache involves sudden, extremely painful headaches that occur in "clusters," usually at the same time of the day and night for several weeks. They strike one side of the head, often behind or around one eye, and may be preceded by a migraine-like aura and nausea. The pain usually peaks five to 10 minutes after onset and continues at that intensity for up to three hours. The nose and the eye on the affected side of the face may get red, swollen and teary. Some people will experience restlessness and agitation, changes in heart rate and blood pressure, and sensitivity to light, sound or smell. These headaches often wake people from sleep.

Chronic daily headache refers to a group of headache disorders that occur at least 15 days a month during a three-month period. In addition to chronic tension-type headache, chronic migraine and medication overuse headache (discussed above), these headaches include hemicrania continua and new daily persistent headaches. Individuals feel constant, mostly moderate pain throughout the day on the sides or top of the head. They may also experience other types of headache. Adolescents and adults may experience chronic daily headaches. In children, stress from school and family activities may contribute to these headaches.

• Hemicrania continua is marked by continuous, fluctuating pain that always occurs on the same side of the face and head. The headache may last from minutes to days and is associated with symptoms including tearing, red and irritated eyes, sweating, stuffy or runny nose, and swollen and drooping eyelids. The pain may get worse as the headache progresses. Migraine-like symptoms include nausea, vomiting and sensitivity to light and sound. Physical exertion and alcohol use may increase headache severity. The disorder is more common in women than in men and its cause is unknown. Hemicrania continua has two forms: chronic, with daily headaches, and remitting or episodic, in which headaches may occur over a period of six months and are followed by a pain-free period of weeks to months before recurring. Most individuals have attacks of increased pain three to five times per 24-hour cycle. The nonsteroidal anti-inflammatory drug indomethacin usually provides rapid relief from symptoms. Corticosteroids may also provide temporary relief from some symptoms. For additional information on hemicrania continua, see the National Institute of Neurological Disorders and Stroke (NINDS) information page.
• New daily persistent headache (NDPH), previously called chronic benign daily headache, is known for its constant daily pain that ranges from mild to severe. Individuals can often recount the exact date and time that the headache began. Daily headaches can occur for more than three months (and sometimes years) without lessening or ending. Symptoms include:
  • An abnormal sensitivity to light or sound
  • Nausea
  • Lightheadedness
  • A pressing, throbbing or tightening pain felt on both sides of the head

NDPH occurs more often in women than in men. Most sufferers do not have a prior history of headache. NDPH may occur spontaneously or following infection, medication use, trauma, high spinal fluid pressure or other conditions. The disorder has two forms: one that usually ends on its own within several months and does not require treatment, and a longer-lasting form that is difficult to treat. Muscle relaxants, antidepressants and anticonvulsants may provide some relief.

The other types of headache disorders include: 

• Tension-type headache (TTH)
• Cluster headache (CH)
• Medication-overuse headache (MOH)

Tension-type headaches also may be caused by:

• Jaw clenching
• Intense work
• Missed meals
• Depression
• Anxiety
• Not enough sleep

Sleep apnea also may cause tension-type headaches, especially in the morning. The pain is usually mild to moderate and feels as if constant pressure is being applied to the front of the face or to the head or neck. It also may feel as if a belt is being tightened around the head. Most often the pain is felt on both sides of the head. People who suffer tension-type headaches also may feel overly sensitive to light and sound, but there is no pre-headache aura as with migraine. Typically, tension-type headaches usually disappear once the period of stress or related cause has ended.

Tension-type headaches affect women slightly more often than men. The headaches usually begin in adolescence and reach peak activity in the 30s. They have not been linked to hormones and do not have a strong hereditary connection. 

Depression and anxiety can cause tension-type headaches. Headaches may appear in the early morning or evening, when conflicts in the office or at home are anticipated. Other causes include physical postures that strain head and neck muscles (such as holding your chin down while reading or holding a phone between your shoulder and ear), degenerative arthritis of the neck, and temporomandibular joint dysfunction (a disorder of the joints between the temporal bone located above the ear and the mandible, or lower jaw bone).

Cluster headaches occur more often at night than during the day, suggesting they could be caused by irregularities in the body's sleep-wake cycle. Alcohol (especially red wine) and smoking can provoke attacks. Studies show a connection between cluster headache and prior head trauma. An increased familial risk of these headaches suggests that there may be a genetic cause.

Hemicrania continua, a type of chronic daily headache, is diagnosed in both adolescents and adults as a chronic daily headache. In children, stress from school and family activities may contribute to these headaches. Physical exertion and alcohol use may increase headache severity. The disorder is more common in women than in men, and its cause is unknown. 

New daily persistent headache (NDPH) occurs more often in women than in men. Most sufferers do not have a prior history of headache. NDPH may occur spontaneously or following infection, medication use, trauma, high spinal fluid pressure or other conditions. The disorder has two forms: one that usually ends on its own within several months and does not require treatment, and a longer-lasting form that is difficult to treat. 

A number of different factors can increase your risk of having a headache. These factors, which trigger the headache process, vary from person to person and include:

• Sudden changes in weather or environment
• Too much or not enough sleep
• Strong odors or fumes
• Emotion
• Stress
• Overexertion
• Loud or sudden noises
• Motion sickness
• Low blood sugar
• Skipped meals
• Tobacco
• Depression
• Anxiety
• Head trauma
• Hangover
• Some medications
• Hormonal changes
• Bright or flashing lights

Medication overuse or missed doses also may cause headaches. Foods or ingredients like the ones listed below can trigger headaches; keeping a diet journal can help you identify your triggers.

• Aspartame
• Caffeine (or caffeine withdrawal)
• Wine and other types of alcohol
• Chocolate
• Aged cheeses
• Monosodium glutamate (MSG)
• Some fruits and nuts
• Fermented or pickled goods
• Yeast
• Cured or processed meats

Lifestyle habits that increase risk of headache attacks in some individuals include lack of exercise, eating food and beverages that trigger headaches, an irregular eating schedule and inadequate hydration, starting or stopping certain medications, and an inconsistent sleep schedule. Obesity increases the risk of developing chronic daily headaches, so a weight loss program is recommended for those who are over a healthy weight.

Additionally, studies show a connection between cluster headaches and prior head trauma. An increased familial risk of these headaches suggests that there may be a genetic cause.

Preventive treatment involves taking medicines daily to reduce the severity of future attacks or keep them from happening. The U.S. Food and Drug Administration (FDA) has approved the drugs erenumab (Aimovig) for the preventive treatment of headache and galcanezumab-gnlm (Emgality) injections to treat episodic cluster headache. The FDA also has approved lasmiditan (Reyvow) and ubrogepant (Ubrelvy) tablets for short-term treatment of migraine with or without aura. Headache drug use should be monitored by a physician, since some drugs may cause side effects.

Lifestyle changes that reduce or prevent migraine attacks in some individuals include exercising, avoiding food and beverages that trigger headaches, eating regularly scheduled meals with adequate hydration, stopping certain medications, and establishing a consistent sleep schedule. Obesity increases the risk of developing chronic daily headaches, so a weight loss program is recommended for obese individuals.

Not all headaches require a physician's attention. But headaches can signal a more serious disorder that requires prompt medical care. Immediately call or see a physician if you or someone you're with experiences any of these symptoms:

• Sudden, severe headache that may be accompanied by a stiff neck
• Severe headache accompanied by fever, nausea or vomiting that is not related to another illness
• "First" or "worst" headache, often accompanied by confusion, weakness, double vision or loss of consciousness
• Headache that worsens over days or weeks or has changed in pattern or behavior
• Recurring headache in children
• Headache following a head injury
• Headache and a loss of sensation or weakness in any part of the body, which could be a sign of a stroke
• Headache associated with convulsions and/or shortness of breath
• Two or more headaches a week
• Persistent headache in someone who has been previously headache-free, particularly in someone over age 50
• New headaches in someone with a history of cancer or HIV/AIDS

Tension headache symptoms can be identified by frequency, occurring more than 15 days each month. They typically last a few hours, but can sometimes stretch to multiple days. Tension headaches feel like pressure or tightness around the circumference of the head, often spreading into the neck. 

Cluster headaches recur several times a day and are more brief than tension headaches. Symptoms are severe and focused around the eye. Other identifiable factors include a runny nose, blocked nasal passage, and/or tearing or redness in the eye.

How and under what circumstances a person experiences a headache can be key to diagnosing its cause. Keeping a headache journal can help a physician better diagnose your type of headache and determine the best treatment. After each headache, note:

• The time of day when it occurred
• Its intensity and duration
• Any sensitivity to light, odors or sound
• Activity immediately prior to the headache
• Use of prescription and nonprescription medicines
• Amount of sleep the previous night
• Any stressful or emotional conditions
• Any influence from weather or daily activity
• Foods and fluids consumed in the past 24 hours
• Any known health conditions at that time

Women should record the days of their menstrual cycles. Include notes about other family members who have a history of headache or other disorders. A pattern may emerge that can be helpful to reducing or preventing headaches.

Once your doctor reviews your medical and headache history and conducts physical and neurological exams, lab screening and diagnostic tests may be ordered to either rule out or identify conditions that might be the cause of your headaches.

Blood and urine tests can help diagnose brain or spinal cord infections, blood vessel damage and toxins that affect the nervous system. Testing the fluid that surrounds the brain and spinal cord can detect infections, bleeding in the brain (called a brain hemorrhage), and measure any buildup of pressure within the skull.

Diagnostic imaging, such as with computed tomography (CT) and magnetic resonance imaging (MRI), can detect irregularities in blood vessels and bones, certain brain tumors and cysts, brain damage from head injury, brain hemorrhage, inflammation, infection and other disorders. Neuroimaging also gives doctors a way to see what's happening in the brain during headache attacks. An electroencephalogram (EEG) measures brain wave activity and can help diagnose brain tumors, seizures, head injury and inflammation that may lead to headaches.

Tension-type headache is the most common type of headache. Its name indicates the role of stress and mental or emotional conflict in triggering the pain and contracting muscles in the neck, face, scalp and jaw. Tension-type headaches also may be caused by:

• Jaw clenching
• Intense work
• Missed meals
• Depression
• Anxiety
• Not enough sleep

Sleep apnea also may cause tension-type headaches, especially in the morning. The pain is usually mild to moderate and feels as if constant pressure is being applied to the front of the face or to the head or neck. It also may feel as if a belt is being tightened around the head. Most often the pain is felt on both sides of the head. People who suffer tension-type headaches also may feel overly sensitive to light and sound, but there is no pre-headache aura as with migraine. Typically, tension-type headaches usually disappear once the period of stress or related cause has ended.

Tension-type headaches affect women slightly more often than men. The headaches usually begin in adolescence and reach peak activity in the 30s. They have not been linked to hormones and do not have a strong hereditary connection.

There are two forms of tension-type headache:

1. Episodic tension-type headaches occur between 10 and 15 days per month, with each attack lasting from 30 minutes to several days. Although the pain is not disabling, the severity of pain typically increases with the frequency of attacks.
2. Chronic tension-type attacks usually occur more than 15 days per month over a three-month period. The pain, which can be constant over a period of days or months, strikes both sides of the head and is more severe and disabling than episodic headache pain. Chronic tension headaches can cause sore scalps—even combing your hair can be painful. Most individuals will have had some form of episodic tension-type headache prior to onset of chronic tension-type headache.

Depression and anxiety can cause tension-type headaches. Headaches may appear in the early morning or evening, when conflicts in the office or at home are anticipated. Other causes include physical postures that strain head and neck muscles (such as holding your chin down while reading or holding a phone between your shoulder and ear), degenerative arthritis of the neck, and temporomandibular joint dysfunction (a disorder of the joints between the temporal bone located above the ear and the mandible, or lower jaw bone).

The first step in caring for a tension-type headache involves treating any specific disorder or disease that may be causing it. For example, arthritis of the neck is treated with anti-inflammatory medication, and temporomandibular joint dysfunction may be helped by corrective devices for the mouth and jaw. A sleep study may be needed to detect sleep apnea and should be considered when there is a history of snoring, daytime sleepiness or obesity.

A physician may suggest using analgesics, nonsteroidal anti-inflammatory drugs or antidepressants to treat a tension-type headache that is not associated with a disease. Triptan drugs, barbiturates (drugs that have a relaxing or sedative effect) and ergot derivatives may provide relief to people who suffer from both migraine and tension-type headaches.

Alternative therapies for chronic tension-type headaches include biofeedback, relaxation training, meditation and cognitive behavioral therapy to reduce stress. A hot shower or moist heat applied to the back of the neck may ease symptoms of infrequent tension headaches. Physical therapy, massage and gentle exercise of the neck also may be helpful.

Cluster headaches generally begin between the ages of 20 and 50 but may start at any age, occur more often in men than in women, and are more common in smokers than in nonsmokers. The attacks are usually less frequent and shorter than migraines. It's common to have one to three cluster headaches a day with two cluster periods a year, separated by months of freedom from symptoms. The cluster periods often appear seasonally, usually in the spring and fall, and may be mistaken for allergies. A small group of people develop a chronic form of the disorder, which is characterized by bouts of headaches that can go on for years with only brief periods (one month or less) of remission. Cluster headaches occur more often at night than during the day, suggesting they could be caused by irregularities in the body's sleep-wake cycle. Alcohol (especially red wine) and smoking can provoke attacks. Studies show a connection between cluster headache and prior head trauma. An increased familial risk of these headaches suggests that there may be a genetic cause.

Treatment options include noninvasive vagus nerve stimulation (which uses a handheld device to provide electrical stimulation to the vagus nerve through the skin), galcanezumab-gnlm injections, triptan drugs and oxygen therapy (in which pure oxygen is inhaled through a mask to reduce blood flow to the brain). Certain antipsychotic drugs, calcium-channel blockers and anticonvulsants can reduce pain severity and frequency of attacks. In extreme cases, electrical stimulation of the occipital nerve to prevent nerve signaling or surgical procedures that destroy or cut certain facial nerves may provide relief.

Sufferers of headache disorders have a compromised quality of life due to repeated headache attacks that last for hours and sometimes days. It can be difficult to deal with long-term, chronic pain, which may lead to isolation and social anxiety due to fear of environmental factors that may cause an episode. As a result, some sufferers develop co-occurring anxiety symptoms and mood disorders like depression. 

Consider participating in a clinical trial so clinicians and scientists can learn more about migraine and related disorders. Clinical research uses human volunteers to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat or prevent disease.

All types of volunteers are needed—those who are healthy or may have an illness or disease—of all different ages, sexes, races and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them.