Woman with a headache
The brain tissue itself is not sensitive to pain as it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Nine areas of the head and neck have these pain-sensitive structures, which are the cranium (the periosteum of the skull), muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes. There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society. Headache is a non-specific symptom, which means that it has many possible causes.
Treatment of a headache depends on the underlying cause, but commonly involves pain killers.
- 1 Cause
- 2 Pathophysiology
- 3 Diagnosis
- 4 Management
- 5 Epidemiology
- 6 History
- 7 Children
- 8 References
- 9 External links
There are more than 200 types of headaches. Some are harmless and some are life-threatening. The description of the headache and findings on neurological examination, determine whether additional tests are needed and what treatment is best.
Primary vs. secondary headaches
Headaches are broadly classified as "primary" or "secondary". Primary headaches are benign, recurrent headaches not caused by underlying disease or structural problems. For example, migraine is a type of primary headache. While primary headaches may cause significant daily pain and disability, they are not dangerous. Secondary headaches are caused by an underlying disease, like an infection, head injury, vascular disorders, brain bleed or tumors. Secondary headaches can be harmless or dangerous. Certain "red flags" or warning signs indicate a secondary headache may be dangerous.
90% of all headaches are primary headaches. Primary headaches usually first start when people are between 20 and 40 years old . The most common types of primary headaches are migraines and tension-type headaches. They have different characteristics. Migraines typically present with pulsing head pain, nausea, photophobia (sensitivity to light) and phonophobia (sensitivity to sound). Tension-type headaches usually present with non-pulsing “bandlike” pressure on both sides of the head, not accompanied by other symptoms. Other very rare types of primary headaches include:
- cluster headaches: short episodes (15–180 minutes) of severe pain, usually around one eye, with autonomic symptoms (tearing, red eye, nasal congestion) which occur at the same time every day. Cluster headaches can be treated with triptans and prevented with prednisone, ergotamine or lithium.
- trigeminal neuralgia: shooting face pain
- hemicrania continua: continuous unilateral pain with episodes of severe pain. Hemicrania continua can be relieved by the medication indomethacin.
- primary stabbing headache: recurrent episodes of stabbing "ice pick pain" or "jabs and jolts" for 1 second to several minutes without autonomic symptoms (tearing, red eye, nasal congestion). These headaches can be treated with indomethacin.
- primary cough headache: starts suddenly and lasts for several minutes after coughing, sneezing or straining (anything that may increase pressure in the head). Serious etiologies(see secondary headaches red flag section) must be ruled out before a diagnosis of "benign" primary cough headache can be made.
- primary exertional headache: throbbing, pulsatile pain which starts during or after exercising, lasting for 5 minutes to 24 hours. The mechanism behind these headaches is unclear, possibly due to straining causing veins in the head to dilate, causing pain. These headaches can be prevented by not exercising too strenuously and can be treated with medications such as indomethacin.
- primary sex headache: dull, bilateral headache that starts during sexual activity and becomes much worse during orgasm. These headaches are thought to be due to lower pressure in the head during sex. It is important to realize that headaches that begin during orgasm may be due to a subarachnoid hemorrhage, so serious causes must be ruled out first. These headaches are treated by advising the person to stop sex if they develop a headache. Medications such as propranolol and diltiazem can also be helpful.
- hypnic headache: moderate-severe headache that starts a few hours after falling asleep and lasts 15–30 minutes. The headache may recur several times during night. Hypnic headaches are usually in older women. They may be treated with lithium.
Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication overuse headache may occur in those using excessive painkillers for headaches, paradoxically causing worsening headaches.
More serious causes of secondary headaches include:
- meningitis: inflammation of the meninges which presents with fever and meningismus, or stiff neck
- bleeding inside the brain (intracranial hemorrhage)
- subarachnoid hemorrhage (acute, severe headache, stiff neck WITHOUT fever)
- ruptured aneurysm, arteriovenous malformation, intraparenchymal hemorrhage (headache only)
- brain tumor: dull headache, worse with exertion and change in position, accompanied by nausea and vomiting. Often, the person will have nausea and vomiting for weeks before the headache starts.
- temporal arteritis: inflammatory disease of arteries common in the elderly (average age 70) with fever, headache, weight loss, jaw claudication, tender vessels by the temples, polymyalgia rheumatica
- acute closed angle glaucoma (increased pressure in the eyeball): headache that starts with eye pain, blurry vision, associated with nausea and vomiting. On physical exam, the person will have a red eye and a fixed, mid dilated pupil.
The brain itself is not sensitive to pain, because it lacks pain receptors, also called nociceptors. However, several areas of the head and neck do have nociceptors, and can thus sense pain. These include the extracranial arteries, middle meningeal artery, large veins, venous sinuses, cranial and spinal nerves, head and neck muscles, the meninges, falx cerebri, parts of the brainstem, eyes, ears, teeth and lining of the mouth. Pial arteries, rather than pial veins are responsible for pain production.
Headaches often result from traction to or irritation of the meninges and blood vessels. The nociceptors may be stimulated by head trauma or tumors and cause headaches. Blood vessel spasms, dilated blood vessels, inflammation and/or infection of meninges and muscular tension can also stimulate nociceptors and cause pain. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts.
Primary headaches are more difficult to understand than secondary headaches. The exact mechanisms which cause migraines, tension headaches and cluster headaches are not known. There have been different theories over time which attempt to explain what happens in the brain to cause these headaches.
Migraines are currently thought to be caused by dysfunction of the nerves in the brain. Previously, migraines were thought to be caused by a primary problem with the blood vessels in the brain. This vascular theory, which was developed in the 20th century by Wolff, suggested that the aura in migraines is caused by constriction of intracranial vessels (vessels inside the brain), and the headache itself is caused by rebound dilation of extracranial vessels (vessels just outside of the brain). Dilation of these extracranial blood vessels activates the pain receptors in the surrounding nerves, causing a headache. The vascular theory is no longer accepted. Studies have shown migraine head pain is not accompanied by extracranial vasodilation, but rather only has some mild intracranial vasodilation.
Currently, most specialists think migraines are due to a primary problem with the nerves in the brain. Auras are thought to be caused by a wave of increased activity of neurons in the cerebral cortex (a part of the brain) known as cortical spreading depression followed by a period of depressed activity. Some people think headaches are caused by the activation of sensory nerves which release peptides, such as serotonin, causing inflammation in arteries, dura and meninges and also cause some vasodilation. Triptans, medications which treat migraines, blocks serotonin receptors and constrict blood vessels.
People who are more susceptible to experience migraines without headache are those who have a family history of migraines, women, and women who are experiencing hormonal changes or are taking birth control pills or are prescribed hormone replacement therapy.
|Tension headache||New daily persistent headache||Cluster headache||Migraine|
|mild to moderate dull or aching pain||severe pain||moderate to severe pain|
|duration of 30 minutes to several hours||duration of at least four hours daily||duration of 30 minutes to 3 hours||duration of 4 hours to 3 days|
|Occur in periods of 15 days a month for three months||may happen multiple times in a day for months||periodic occurrence; several per month to several per year|
|located as tightness or pressure across head||located on one or both sides of head||located one side of head focused at eye or temple||located on one or both sides of head|
|consistent pain||pain describable as sharp or stabbing||pulsating or throbbing pain|
|no nausea or vomiting||nausea, perhaps with vomiting|
|no aura||no aura||auras|
|uncommonly, light sensitivity or noise sensitivity||may be accompanied by running nose, tears, and drooping eyelid, often only on one side||sensitivity to movement, light, and noise|
|exacerbated by regular use of acetaminophen or NSAIDS||may exist with tension headache|
Most headaches can be diagnosed by the clinical history alone. If the symptoms described by the person sound dangerous, further testing with neuroimaging and/or lumbar puncture may be necessary. Electroencephalography (EEG) is not useful for headache diagnosis.
The first step to diagnosing a headache is to determine if the headache is old or new. A "new headache" can be a headache that has started recently, or a chronic headache that has changed character. For example, if a person has chronic weekly headaches with pressure on both sides of his head, and then develops a sudden severe throbbing headache on one side of his head, he has a new headache.
It can be challenging to differentiate between low-risk, benign headaches and high-risk, dangerous headaches since symptoms are often similar. Headaches that are possibly dangerous require further lab tests and imaging to diagnose.
The American College for Emergency Physicians published criteria for low-risk headaches. They are as follows:
- age younger than 30 years
- features typical of primary headache
- history of similar headache
- no abnormal findings on neurologic exam
- no concerning change in normal headache pattern
- no high-risk comorbid conditions (for example, HIV)
- no new concerning history or physical examination findings
A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes which may be life-threatening or cause long-term damage. These "red flag" symptoms means that a headache warrants further investigation with neuroimaging and lab tests.
In general, people complaining of their "first" or "worst" headache warrant imaging and further workup. People with progressively worsening headache also warrant imaging, as they may have a mass or a bleed that is gradually growing, pressing on surrounding structures and causing worsening pain. People with neurological findings on exam, such as weakness, also need further workup.
The American Headache Society recommends using "SSNOOP", a mnemonic to remember the red flags for identifying a secondary headache:
- Systemic symptoms (fever or weight loss)
- Systemic disease (HIV infection, malignancy)
- Neurologic symptoms or signs
- Onset sudden (thunderclap headache)
- Onset after age 40 years
- Previous headache history (first, worst, or different headache)
|Red Flag||Possible causes||Reason why red flag indicates possible causes||Diagnostic tests|
|New headache after age 50||Temporal arteritis, mass in brain||Temporal arteritis is an inflammation of vessels close to the temples in older people, which decreases blood flow to the brain and causes pain. May also have tenderness in temples and/or jaw claudication. Some brain cancers are more common in older people.||Erythrocyte sedimentation rate (diagnostic test for temporal arteritis), neuroimaging|
|Very sudden onset headache (thunderclap headache)||Brain bleed (subarachnoid hemorrhage, hemorrhage into mass lesion, vascular malformation), pituitary apoplexy, mass (especially in posterior fossa)||A bleed in the brain irritates the meninges which causes pain. Pituitary apoplexy (bleeding or impaired blood supply to the pituitary gland at the base of the brain) is often accompanied by double vision or visual field defects, since the pituitary gland is right next to the optic chiasm (eye nerves).||Neuroimaging, lumbar puncture if computed tomography is negative|
|Headaches increasing in frequency and severity||Mass, subdural hematoma, medication overuse||As a brain mass gets larger, or a subdural hematoma (blood outside the vessels underneath the dura) it pushes more on surrounding structures causing pain. Medication overuse headaches worsen with more medication taken over time.||Neuroimaging, drug screen|
|New onset headache in a person with possible HIV or cancer||Meningitis (chronic or carcinomatous), brain abscess including toxoplasmosis, metastasis||People with HIV or cancer are immunosuppressed so are likely to get infections of the meninges or infections in the brain causing abscesses. Cancer can metastasize, or travel through the blood or lymph to other sites in the body.||Neuroimaging, lumbar puncture if neuroimaging is negative|
|Headache with signs of total body illness (fever, stiff neck, rash)||Meningitis, encephalitis (inflammation of the brain tissue), Lyme disease, collagen vascular disease||A stiff neck, or inability to flex the neck due to pain, indicates inflammation of the meninges. Other signs of systemic illness indicates infection.||Neuroimaging, lumbar puncture, serology (diagnostic blood tests for infections)|
|Papilledema||brain mass, benign intracranial hypertension (pseudotumor cerebri), meningitis||Increased intracranial pressure pushes on the eyes (from inside the brain) and causes papilledema.||Neuroimaging, lumbar puncture|
|Headache following head trauma||Brain bleeds (intracranial hemorrhage, subdural hematoma, epidural hematoma), post-traumatic headache||Trauma can cause bleeding in the brain or shake the nerves, causing a post-traumatic headache||Trauma can cause bleeding in the brain or shake the nerves, causing a post-traumatic headache Neuroimaging of brain, skull and possibly cervical spine|
|Inability to move a limb||Arteriovenous malformation, collagen vascular disease, intracranial mass lesion||Focal neurological signs indicate something is pushing against nerves in the brain responsible for one part of the body||Neuroimaging, blood tests for collagen vascular diseases|
|Change in personality, consciousness, or mental status||Central nervous system infection, intracranial bleed, mass||Change in mental status indicates a global infection or inflammation of the brain, or a large bleed compressing the brainstem where the consciousness centers lie||Blood tests, lumbar puncture, neuroimaging|
|Headache triggered by cough, exertion or while engaged in sexual intercourse||Mass lesion, subarachnoid hemorrhage||Coughing and exertion increases the intra cranial pressure, which may cause a vessel to burst, causing a subarachnoid hemorrhage. A mass lesion already increases intracranial pressure, so an additional increase in intracranial pressure from coughing etc. will cause pain.||Neuroimaging, lumbar puncture|
Old headaches are usually primary headaches and are not dangerous. They are most often caused by migraines or tension headaches. Migraines are often unilateral, pulsing headaches accompanied by nausea and/or vomiting. There may be an aura (visual symptoms, numbness or tingling) 30–60 minutes before the headache, warning the person of a headache. Migraines may also not have auras. Tension type headaches usually have bilateral "bandlike" pressure on both sides of the head usually without nausea or vomiting. However, some symptoms from both headache groups may overlap. It is important to distinguish between the two because the treatments are different.
The mnemonic 'POUND' helps distinguish between migraines and tension type headaches. POUND stands for Pulsatile quality, 4–72 hOurs in length, Unilateral location, Nausea or vomiting, Disabling intensity. One review article found that if 4–5 of the POUND characteristics are present, migraine is 24 times as likely a diagnosis than tension type headache (likelihood ratio 24). If 3 characteristics of POUND are present, migraine is 3 times more likely a diagnosis than tension type headache (likelihood ratio 3). If only 2 POUND characteristics are present, tension type headaches are 60% more likely (likelihood ratio 0.41). Another study found the following factors independently each increase the chance of migraine over tension type headache: nausea, photophobia, phonophobia, exacerbation by physical activity, unilateral, throbbing quality, chocolate as headache trigger, cheese as headache trigger.
Cluster headaches are relatively rare (1–3 in 10,000 people) and are more common in men than women. They present with sudden onset explosive pain around one eye and are accompanied by autonomic symptoms (tearing, runny nose and red eye).
For chronic, unexplained headaches, keeping a headache diary can be useful for tracking symptoms and identifying triggers, such as association with menstrual cycle, exercise and food. The National Migraine Center has free headache diaries to download at their website. While mobile electronic diaries for smartphones are becoming increasingly common, a recent review found most are developed with a lack of evidence base and scientific expertise. 
New headaches are more likely to be dangerous secondary headaches. They can, however, simply be the first presentation of a chronic headache syndrome, like migraine or tension-type headaches.
One recommended diagnostic approach is as follows. If any urgent red flags are present such as visual loss, new seizures, new weakness, new confusion, further workup with imaging and possibly a lumbar puncture should be done (see red flags section for more details). If the headache is sudden onset (thunderclap headache), a computed tomography test to look for a brain bleed (subarachnoid hemorrhage) should be done. If the CT scan does not show a bleed, a lumbar puncture should be done to look for blood in the CSF, as the CT scan can be falsely negative and subarachnoid hemorrhages can be fatal. If there are signs of infection such as fever, rash, or stiff neck, a lumbar puncture to look for meningitis should be considered. If there is jaw claudication and scalp tenderness in an older people, a temporal artery biopsy to look for temporal arteritis should be performed and immediate treatment should be started.
The US Headache Consortium has guidelines for neuroimaging of non-acute headaches. Most old, chronic headaches do not require neuroimaging. If a person has the characteristic symptoms of a migraine, neuroimaging is not needed as it is very unlikely the person has an intracranial abnormality. If the person has neurological findings, such as weakness, on exam, neuroimaging may be considered.
All people who present with red flags indicating a dangerous secondary headache should receive neuroimaging. The best form of neuroimaging for these headaches is controversial. Non-contrast computerized tomography (CT) scan is usually the first step in head imaging as it is readily available in Emergency Departments and hospitals and is cheaper than MRI. Non-contrast CT is best for identifying an acute head bleed. Magnetic Resonance Imaging (MRI) is best for brain tumors and problems in the posterior fossa, or back of the brain. MRI is more sensitive for identifying intracranial problems, however it can pick up brain abnormalities that are not relevant to the person's headaches.
The American College of Radiology recommends the following imaging tests for different specific situations:
|Clinical Features||Recommended neuroimaging test|
|Headache in immunocompromised people (cancer, HIV)||MRI of head with or without contrast|
|Headache in people older than 60 with suspected temporal arteritis||MRI of head with or without contrast|
|Headache with suspected meningitis||CT or MRI without contrast|
|Severe headache in pregnancy||CT or MRI without contrast|
|Severe unilateral headache caused by possible dissection of carotid and/or arterial arteries||MRI of head with or without contrast, Magnetic Resonance Angiography or Computed Tomography Angiography of head and neck.|
|Sudden onset headache or worst headache of life||CT of head without contrast, Computed Tomography Angiography of head and neck with contrast, Magnetic Resonance Angiography of head and neck with and without contrast, MRI of head without contrast|
A lumbar puncture is a procedure in which cerebral spinal fluid is removed from the spine with a needle. A lumbar puncture is necessary to look for infection or blood in the spinal fluid. A lumbar puncture can also evaluate the pressure in the spinal column, which can be useful for people with idiopathic intracranial hypertension (usually young, obese women who have increased intracranial pressure), or other causes of increased intracranial pressure. In most cases, a CT scan should be done first.
Headaches are most thoroughly classified by the International Headache Society's International Classification of Headache Disorders (ICHD), which published the second edition in 2004. This classification is accepted by the WHO.
The International Classification of Headache Disorders (ICHD) is an in-depth hierarchical classification of headaches published by the International Headache Society. It contains explicit (operational) diagnostic criteria for headache disorders. The first version of the classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in 2004.
The classification uses numeric codes. The top, one-digit diagnostic level includes 13 headache groups. The first four of these are classified as primary headaches, groups 5-12 as secondary headaches, cranial neuralgia, central and primary facial pain and other headaches for the last two groups.
The ICHD-2 classification defines migraines, tension-types headaches, cluster headache and other trigeminal autonomic cephalalgias as the main types of primary headaches. Also, according to the same classification, stabbing headaches and headaches due to cough, exertion and sexual activity (coital cephalalgia) are classified as primary headaches. The daily-persistent headaches along with the hypnic headache and thunderclap headaches are considered primary headaches as well.
Secondary headaches are classified based on their etiology and not on their symptoms. According to the ICHD-2 classification, the main types of secondary headaches include those that are due to head or neck trauma such as whiplash injury, intracranial hematoma, post craniotomy or other head or neck injury. Headaches caused by cranial or cervical vascular disorders such as ischemic stroke and transient ischemic attack, non-traumatic intracranial hemorrhage, vascular malformations or arteritis are also defined as secondary headaches. This type of headaches may also be caused by cerebral venous thrombosis or different intracranial vascular disorders. Other secondary headaches are those due to intracranial disorders that are not vascular such as low or high pressure of the cerebrospinal fluid pressure, non-infectious inflammatory disease, intracranial neoplasm, epileptic seizure or other types of disorders or diseases that are intracranial but that are not associated with the vasculature of the central nervous system. ICHD-2 classifies headaches that are caused by the ingestion of a certain substance or by its withdrawal as secondary headaches as well. This type of headache may result from the overuse of some medications or by exposure to some substances. HIV/AIDS, intracranial infections and systemic infections may also cause secondary headaches. The ICHD-2 system of classification includes the headaches associated with homeostasis disorders in the category of secondary headaches. This means that headaches caused by dialysis, high blood pressure, hypothyroidism, and cephalalgia and even fasting are considered secondary headaches. Secondary headaches, according to the same classification system, can also be due to the injury of any of the facial structures including teeth, jaws, or temporomandibular joint. Headaches caused by psychiatric disorders such as somatization or psychotic disorders are also classified as secondary headaches.
The ICHD-2 classification puts cranial neuralgias and other types of neuralgia in a different category. According to this system, there are 19 types of neuralgias and headaches due to different central causes of facial pain. Moreover, the ICHD-2 includes a category that contains all the headaches that cannot be classified.
Although the ICHD-2 is the most complete headache classification there is and it includes frequency in the diagnostic criteria of some types of headaches (primarily primary headaches), it does not specifically code frequency or severity which are left at the discretion of the examiner.
The NIH classification consists of brief definitions of a limited number of headaches.
The NIH system of classification is more succinct and only describes five categories of headaches. In this case, primary headaches are those that do not show organic or structural etiology. According to this classification, headaches can only be vascular, myogenic, cervicogenic, traction and inflammatory.
Primary headache syndromes have many different possible treatments.
Migraines can be somewhat improved by lifestyle changes, but most people require medicines to control their symptoms. Medications are either prophylactic (to prevent getting migraines), or "abortive" (reduce symptoms once a migraine starts). The same medications do not work for all people. People with migraines should work with their doctors to find the medication regimen that is best for them.
Several complementary and alternative strategies can help with migraines. The American Academy of Neurology guidelines for migraine treatment in 2000 stated relaxation training, electromyographic feedback and cognitive behavioral therapy may be considered for migraine treatment, along with medications. Clinical trials have found that acupuncture can be just as helpful in preventing migraines as medications. In one study, acupuncture reduced headache days by 2.3 days over 25 weeks and medication reduced headache days by 2.1 days over 25 weeks. However, in this study, acupunture was just as good as "sham acupuncture" (reduced headache days by 1.5 days over 25 weeks), when the acupuncture needles are not placed in the correct locations. Thus benefits of acupuncture may simply be due to the placebo effect.
Preventive medications are generally recommended when people have more than four attacks of migraine per month, headaches last longer than 12 hours or the headaches are very disabling. Possible therapies include beta blockers, antidepressants, anticonvulsants and NSAIDS. The type of preventive medicine is usually chosen based on the other symptoms the person has. For example, if the person also has depression, an antidepressant is a good choice.
Abortive therapies for migraines may be oral, if the migraine is mild to moderate, or may require stronger medicine given intravenously or intramuscularly. Mild to moderate headaches should first be treated with NSAIDs, like ibuprofen, and/or acetaminophen. If accompanied by nausea or vomiting, an antiemitic such as metoclopramide (Reglan) can be given orally or rectally. Moderate to severe attacks should be treated first with an oral triptan, a medication which mimics serotonin (an agonist) and causes mild vasoconstriction. If accompanied by nausea and vomiting, parenteral (through a needle in the skin) triptans and antiemitics can be given. See Migraine Treatment for more detailed information.
Tension-type headaches can usually be managed with NSAIDs (ibuprofen, naproxen), acetaminophen or aspirin. Triptans are not helpful in tension-type headaches unless the person also has migraines. For chronic tension type headaches, amitryptiline is the only medication proven to help. Amitryptiline is a medication which treats depression and also independently treats pain. It works by blocking the reuptake of serotonin and norepinephrine, and also reduces muscle tenderness by a separate mechanism. Studies evaluating acupuncture for tension-type headaches have been mixed. Overall, they show that acupuncture is probably not helpful for tension-type headaches. More detailed information can be found at tension-type headaches.
Abortive therapy for cluster headaches include subcutaneous sumatriptan (injected under the skin) or triptan nasal sprays. High flow oxygen therapy also helps with relief.
For people with extended periods with cluster headaches, preventive therapy can be necessary. Verapamil is recommended as first line treatment. Lithium can also be useful. For people with shorter bouts, a short course of prednisone (10 days) can be helpful. Ergotamine is useful if given 1–2 hours before an attack. See cluster headaches for more detailed information.
Treatment of secondary headaches involves treating the underlying cause. For example, a person with meningitis will require antibiotics. A person with a brain tumor may require surgery, chemotherapy and/or brain radiation.
Approximately 64–77% of people have a headache at some point in their lives. During each year, on average, 46–53% of people have headaches. Most of these headaches are not dangerous. Only approximately 1–5% of people with headaches who go to the emergency room have a serious underlying cause.
More than 90% of headaches are primary headaches. Most of these primary headaches are tension headaches. Most people with tension headaches have "episodic" tension headaches that come and go. Only 3.3% of adults have chronic tension headaches, with headaches for more than 15 days in a month.
Approximately 12–18% of people in the world have migraines. More women than men experience migraines. In Europe and North America, 5–9% of men experience migraines, while 12–25% of women experience migraines.
Cluster headaches are very rare. They affect only 1–3 per thousand people in the world. Cluster headaches affect approximately three times as many men as women.
The first recorded classification system that resembles the modern ones was published by Thomas Willis, in De Cephalalgia in 1672. In 1787 Christian Baur generally divided headaches into idiopathic (primary headaches) and symptomatic (secondary ones), and defined 84 categories.
Many children have headaches. By the time children are 18 years old, over 90% report having a headache. In general, children suffer from the same types of headaches as adults do, but their symptoms may be slightly different. The diagnostic approach to headache in children is similar to that of adults. However, young children may not be able to verbalize pain well. If a young child is fussy, he may have a headache.
Approximately 1% of Emergency Department visits for children are for headache. Most of these headaches are not dangerous. The most common type of headache seen in pediatric Emergency Rooms is headache caused by a cold (28.5%). Other headaches diagnosed in the Emergency Department include post-traumatic headache (20%), headache related to a problem with a ventriculoperitoneal shunt (a device put into the brain to remove excess CSF and reduce pressure in the brain) (11.5%) and migraine (8.5%). The most common serious headaches found in children include brain bleeds (subdural hematoma, epidural hematoma), brain abscesses, meningitis and ventriculoperitoneal shunt malfunction. Only 4–6.9% of kids with a headache have a serious cause.
Just as in adults, most headaches are benign, but when head pain is accompanied with other symptoms such as speech problems, muscle weakness, and loss of vision, a more serious underlying cause may exist: hydrocephalus, meningitis, encephalitis, abscess, hemorrhage, tumor, blood clots, or head trauma. In these cases, the headache evaluation may include CT scan or MRI in order to look for possible structural disorders of the central nervous system. If a child with a recurrent headache has a normal physical exam, neuroimaging is not recommended. Guidelines state children with abnormal neurologic exams, confusion, seizures and recent onset of worst headache of life, change in headache type or anything suggesting neurologic problems should receive neuroimaging.
When children complain of headaches, many parents are concerned about a brain tumor. Generally, headaches caused by brain masses are incapacitating and accompanied by vomiting. One study found characteristics associated with brain tumor in children are: headache for greater than 6 months, headache related to sleep, vomiting, confusion, no visual symptoms, no family history of migraine and abnormal neurologic exam.
Some measures can help prevent headaches in children. Drinking plenty of water throughout the day, avoiding caffeine, getting enough and regular sleep, eating balanced meals at the proper times, and reducing stress and excess of activities may prevent headaches. Treatments for children are similar to those for adults, however certain medications such as narcotics should not be given to children.
Children who have headaches will not necessarily have headaches as adults. In one study of 100 children with headache, eight years later 44% of those with tension headache and 28% of those with migraines were headache free. In another study of people with chronic daily headache, 75% did not have chronic daily headaches two years later, and 88% did not have chronic daily headaches eight years later.
- "headache" at Dorland's Medical Dictionary
- Scottish Intercollegiate Guideline Network (November 2008). Diagnosis and management of headache in adults. Edinburgh: NHS Quality Improvement Scotland. ISBN 9781905813391.
- "Primary and Secondary Headaches", Neurology and Neurosurgery "The Headache Center" http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/headache/conditions/primary_vs_secondary_headaches.html
- Goadsby PJ, Raskin NH. Chapter 14. Headache. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
- Clinch C. Chapter 28. Evaluation & Management of Headache. In: South-Paul JE, Matheny SC, Lewis EL. eds. CURRENT Diagnosis & Treatment in Family Medicine, 3e. New York, NY: McGraw-Hill; 2011.http://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=377&Sectionid=40349420. Accessed April 19, 2014.
- Detsky ME, McDonald DR, Baerlocher MR. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006;296:1274–1283. [PubMed: 16968852]
- Edlow, J.A.; Panagos, P.D.; Godwin, S.A.; Thomas, T.L.; Decker, W.W. (October 2008). "Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache". Annals of Emergency Medicine 52 (4): 407–36. doi:10.1016/j.annemergmed.2008.07.001. PMID 18809105.
- Chapter 6. Headache & Facial Pain. In: Greenberg DA, Aminoff MJ, Simon RP. eds. Clinical Neurology, 8e. New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=398&Sectionid=39812243. Accessed April 22, 2014.
- Cutrer, FM, Bajwa A, Sabhat M. Pathophysiology, clinical manifestations and diagnosis of migraine in adults. In: UpToDate, Post TW (Ed), UpToDate, San Francisco, CA. (Accessed on April 23, 2014.)
- Goadsby, P.J. (January 2009). "The vascular theory of migraine--A great story wrecked by the facts". Brain 132 (Pt 1): 6–7. doi:10.1093/brain/awn321. PMID 19098031.
- Charles A. Vasodilation out of the picture as a cause of migraine headache. Lancet Neurol 2013; 12:419.
- Amin FM, Asghar MS, Anders H, et al. Magnetic resonance angiography of intracranial and extracranial arteries in patients with spontaneous migraine without aura: a cross sectional study. Lancet Neurol 2013; published online April 9. http://dx.doi.org/10.1016/S1474-4422(13)70067-X.
- HADJIKHANI, N; SANCHEZ DEL RIO, M; WU, O; et al (2001). "Mechanisms of migraine aura revealed by functional MRI in human visual cortex.". Proc Natl Acad Sci U S A 98: 4687–92.
- Buzzi, M.G.; Moskowitz, M (2005). "The pathophysiology of migraine: year 2005.". J Headache Pain 6: 105–11.
- Denny CJ, Schull MJ. Chapter 159. Headache and Facial Pain. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=348&Sectionid=40381638. Accessed April 22, 2014.
- "Migraine Without Headache". http://www.neurobalancechiropractic.com.au/. Neurobalance. Retrieved 16 July 2014.
- Loder E, Rizzoli P. Tension-type headache. BMJ. 2008:336(7635):88-92.
- Leroux E, Ducros A. Cluster headache. Orphanet J Rare Dis. 2008;3:20. [PubMed: 18651939]
- "Using the triptans to treat: Migraine headaches: Comparing effectiveness, safety, and price". Consumer Reports Best Buy Drugs (Consumers Union of US): 8. March 2013. Retrieved 18 March 2013.
- Gronseth, G.S.; Greenberg, M.K. (July 1995). "The utility of the electroencephalogram in the evaluation of patients presenting with headache: A review of the literature". Neurology 45 (7): 1263–7. doi:10.1212/WNL.45.7.1263. PMID 7617180.
- Smetana GW. Chapter 9. "Headache." In: Henderson MC, Tierney LM, Jr., Smetana GW. eds. The Patient History: An Evidence-Based Approach to Differential Diagnosis. New York, NY: McGraw-Hill; 2012.http://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=500&Sectionid=41026552. Accessed April 19, 2014.
- Abrams, BM (2013). "Factors that cause concern". Med Clin N Am 97 (2): 225–242. doi:10.1016/j.mcna.2012.11.002. PMID 23419623.
- American College of Emergency Physicians. "Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache." Ann Emerg Med. 2002;39(1):108–122.
- Hainer BL, Matheson EM. "Approach to acute headache in adults". American Family Physician 2013. 87(10) 682–687.
- Smetana GW. The diagnostic value of historical features in primary headache syndromes. A comprehensive review. Arch Intern Med. 2000;160:2729–2737.
- Hundert AS, Huguet A, McGrath PJ, Stinson JN, Wheaton M (2014). "Commercially available mobile phone headache diary apps: a systematic review". JMIR Mhealth Uhealth 2 (3): e36. doi:10.2196/mhealth.3452. PMID 25138438.
- Chapter 18. "I Have a Patient with Headache. How Do I Determine the Cause?" In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 2e. New York, NY: McGraw-Hill; 2010. http://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=383&Sectionid=41676347. Accessed April 21, 2014
- Consortium US Headache: Evidence-based guidelines in the primary care setting: Neuroimaging in patients with nonacute headache, 2000.
- American Headache Society (September 2013). "Five Things Physicians and Patients Should Question". Choosing Wisely. American Headache Society. Retrieved 10 December 2013., which cites
- Lewis, D. W.; Dorbad, D. (2000). "The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations". Headache 40 (8): 629–632. doi:10.1046/j.1526-4610.2000.040008629.x. PMID 10971658.
- Silberstein, S. D. (2000). "Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology 55 (6): 754–762. doi:10.1212/WNL.55.6.754. PMID 10993991.
- Health Quality, O. (2010). "Neuroimaging for the evaluation of chronic headaches: An evidence-based analysis". Ontario health technology assessment series 10 (26): 1–57. PMC 3377587. PMID 23074404.
- Strain JD, Strife JL, Kushner DC, et al. Headache. American College of Radiology. "ACR appropriateness criteria." Radiology. 2000;215(suppl):855–860.
- IHS Classification ICHD-II (Online ed.). International Headache Society.
- Olesen et al. 2005, pp. 9–11.
- Brown, M.R. (1951). "The classification and treatment of headache". Medical Clinics of North America 35 (5): 1485–93. PMID 14862569.
- Ad Hoc Committee on Classification of Headache (1962). "Classification of Headache". JAMA 179 (9): 717–8. doi:10.1001/jama.1962.03050090045008.
- Olesen, Jes; Goadsby, Peter J.; Ramadan, Nabih M.; Tfelt-Hansen, Peer; Welch, K. Michael A. (2005). The Headaches (3 ed.). Lippincott Williams & Wilkins. ISBN 0781754003.
- Levin, Morris; Baskin, Steven M.; Bigal, Marcelo E. (2008). Comprehensive Review of Headache Medicine. Oxford University Press. ISBN 0195366735.
- Levin et al. 2008, p. 60.
- Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55:754.
- Diener HC, Kronfeld K, Boewing G, et al. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomised controlled clinical trial. Lancet Neurol 2006; 5:310.
- Linde K, Streng A, Jürgens S, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA 2005; 293:2118.
- Li Y, Zheng H, Witt CM, et al. Acupuncture for migraine prophylaxis: a randomized controlled trial. CMAJ 2012; 184:401.
- Bajwa ZH, Sabahat A. Preventive Treatment of Migraine in Adults. In: UptoDate. Swanson JW (Ed), UpToDate, San Francisco, CA. (Accessed on April 24, 2014).
- Taylor R. Tension type headaches in adults: Preventive treatment. In: UpToDate. Swanson JW (Ed). UpToDate, San Francisco, CA. Accessed on April 24, 2014
- Jackson JL, Shimeall W, Sessums L, et al. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ 2010; 341:c5222.
- Davis MA, Kononowech RW, Rolin SA, Spierings EL. Acupuncture for tension-type headache: a meta-analysis of randomized, controlled trials. J Pain 2008; 9:667.
- Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database Syst Rev 2009; :CD007587.
- Hao XA, Xue CC, Dong L, Zheng Z. Factors associated with conflicting findings on acupuncture for tension-type headache: qualitative and quantitative analyses. J Altern Complement Med 2013; 19:285.
- Melchart D, Streng A, Hoppe A, et al. The acupuncture randomised trial (ART) for tension-type headache--details of the treatment. Acupunct Med 2005; 23:157.
- Melchart D, Streng A, Hoppe A, et al. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ 2005; 331:376.
- Manzoni, GC; Stovner, LJ, J (2010). "Epidemiology of headache.". Handbook of Clinical Neurology 97: 3–22. doi:10.1016/s0072-9752(10)97001-2. PMID 20816407.
- Stovner, LJ; Andree, C, (2010). "Prevalence of headache in Europe: a review for the Eurolight project.". Journal of Headache Pain 11 (4): 289–299. doi:10.1007/s10194-010-0217-0. PMID 20473702.
- Mattu, Amal; Goyal, Deepi; Barrett, Jeffrey W.; Broder, Joshua; DeAngelis, Michael; Deblieux, Peter; Garmel, Gus M.; Harrigan, Richard; Karras, David; L'Italien, Anita; Manthey, David (2007). Emergency medicine: Avoiding the pitfalls and improving the outcomes. Malden, MA: Blackwell / BMJ Books. p. 39. ISBN 1405141662.
- Kunkel, Robert S. (2010-08-01). "Headache". Disease Management Project: Publications. Cleveland Clinic. Retrieved 2010-08-06.
- Barea LM, Tannhauser M, Rotta NT. An epidemiologic study of headache among children and adolescents of southern Brazil. Cephalalgia 1996; 16:545.
- Rothner AD. The evaluation of headaches in children and adolescents. Semin Pediatr Neurol 1995; 2:109.
- Schultz BE, Macias CG. Chapter 130. Headaches in Children. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com.ucsf.idm.oclc.org/content.aspx?bookid=348&Sectionid=40381603. Accessed April 23, 2014.
- Scagni P, Pagliero R: "Headache in an Italian pediatric emergency department." J Headache Pain 9: 83, 2008. [PubMed: 18250964]
- Kan L, Nagelberg J, Maytal J: "Headaches in a pediatric emergency department: etiology, imaging and treatment." Headache 40: 25, 2000. [PubMed: 10759899]
- Burton LJ, Quinn B, Pratt-Cheney JL, et al: "Headache etiology in a pediatric emergency department." Pediatr Emerg Care 13: 1, 1997
- "What Causes Headaches in Children and Adolescents?". WebMD. Retrieved 2010-06-30.
- Medina LS, Kuntz KM, Pomeroy S: "Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies." Pediatrics 108: 255, 2001. [PubMed: 11483785]
- "Headaches in Children". achenet.org. Retrieved 2010-06-30.
- Guidetti V, Galli F, Fabrizi P, et al. "Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study." Cephalalgia 1998; 18:455.
- Wang SJ, Fuh JL, Lu SR. "Chronic daily headache in adolescents: an 8-year follow-up study." Neurology 2009; 73:416.