Headaches

What are some of the most common headache types? 

Primary headache disorders (headaches not caused by a disease) account for the majority of headaches. The most common types of these are tension-type, migraine, and cluster headaches. 

The most frequent causes of secondary headaches (those connected to a medical condition) are medication overuse, infection, trauma, and vascular issues.

How common are tension headaches? 

Tension type headaches (TTHs) are the most common primary headache disorder. They affect about 21% of the population. In fact, TTHs are the second most common disorder globally. Despite this, TTHs are the least studied headache disorder. 

There are three types of TTH: infrequent episodic (headache < 1 day per month), frequent episodic (headaches 1-14 days per month), and chronic (headaches ≥ 15 days per month). Most people who suffer from these headaches have the infrequent episodic type. Women tend to suffer more than men from the frequent episodic and chronic types. Chronic TTNs are usually associated with stress, anxiety, and depression.

Tension type headaches are typically more mild-moderate in pain intensity, and the pain tends to occur bilaterally and is non-throbbing. The pain is often described as “dull, pressure, fullness, or band-like.” Tenderness to the muscles in the head and neck may also be present. 

Tension type headaches can last anywhere from thirty minutes to several days and typically are gradual in development. Physical activity does not worsen these headaches, and there is no associated nausea, vomiting, or light-or-sound sensitivity. 

What causes tension headaches?

The exact cause is not known. Several factors are believed to contribute to the development of this type of headache, including a heightened sensitivity of pain pathways in the nervous system. In the past, it was believed that the origin of pain was muscle contractions but this is no longer a widely held belief. 

It is important to note that there is increased muscle tenderness during an episode of TTH, but this is now thought to be attributed to the sensitized pain system that individuals with this type of headache likely have. Poor posture and other mechanical disorders of the spine and neck may contribute. One small study has shown that people who suffer from TTH have weaker extension muscles in their neck.

What makes a migraine headache different from other headaches?

Migraines are different from other headache types because they tend to be very painful and have other associated symptoms, which are often debilitating. The term migraine headache is often misused for severe headaches of other types, but migraines are recurrent and have distinguishing features. 

Nausea, vomiting, light-or-sound sensitivity, and activity intolerance are common migraine features. They tend to be one-sided more often than tension headaches, and a sensory aura precedes or accompanies the pain for some who suffer from them. Migraines are also associated with a high degree of impairment and are the third leading cause of global disability in people under age 50.

What are red flag symptoms, things that when associated with a headache require urgent evaluation?

There are several systemic symptoms that would warrant an emergent evaluation if they occur with a headache, including fever, chills, vomiting, body aches, weight loss, and night sweats. Individuals who develop an acute headache and have a history of cancer, immune system dysfunction (including HIV), or who are pregnant or in the immediate postpartum period should be evaluated promptly. New onset headaches in individuals older than age 50 should be further investigated.

If there are neurological signs and symptoms such as weakness on one side of the body, numbness, speech or vision changes, confusion, or difficulty walking, urgent evaluation is advised. 

There are also specific qualities of the headache itself that may require emergent evaluation. Headaches that come on very suddenly and reach maximum severity in a few minutes are called thunderclap headaches and require an emergency evaluation.

Other concerning characteristics are changes in normal headache pattern; progression in severity, frequency, or clinical features; pain that does not go away; pain that changes significantly with positional changes; and pain that increases substantially with physical exertion (exercise or sex) or valsalva maneuvers (sneezing, coughing, and/or straining).

When should someone with chronic headaches get further diagnostic testing or see a headache specialist?

If an individual experiences any of the aforementioned “red flag” symptoms or has headache features that suggest a secondary headache, imaging with a head CT or MRI may be advised. 

A consultation with a neurologist or headache specialist is recommended when headaches become very frequent or disabling, when a person experiences multiple medication failures, or when the diagnosis is not clear cut.