Headaches are the most prevalent neurological disorders and among the most frequent symptoms seen in general practice.
50% of the general population have headaches during any given year, and more than 90% report a lifetime history of headache.(1)
What Type of Headache do I Have?
To answer this question, you will have to pay close attention to certain characteristics of your headache. While you may experience different types of headaches at different times, the frequent occurrence of a similar pattern of symptoms will most likely point to a single diagnosis. One aspect of particular importance is the pain itself. For further clarification on understanding your pain, visit the Understanding Pain article. The important characteristics to note in the case of headaches is the site or location of the headache. Is your headache unilateral (affecting one side) or bilateral (affecting both sides?) Is it occipital (affecting the back of your head) or temporal (affecting the side of your head.) What brings about your headache? Is the pain throbbing, or sharp and stabbing, or do you feel as if a band were being placed around your head? What worsens your headache? Do you feel intolerant to bright light and loud sounds. Is it alcohol which triggers your pain, or perhaps chocolate? How long does your headache last and how frequently do you have such episodes. When you do experience pain, how bad is it on a scale of 1-10? All these factors must be considered when diagnosing the possible cause of your headache, allowing a more targeted and effective treatment approach.
Migraine headaches are typically unilateral and occur on one side of the head although that may not always be the case. They are characteristically throbbing or pulsatile headaches which may be brought on by exposure to bright lights or loids sounds in sone patients. Migraine headaches may last between 4-72 hours and may occur several times in the same week. Some patients with migraine headaches report an “aura” prior to the onset of the headache. This is basically a sensation or feeling that occurs just prior to the headache. This may occur in the form of visual disturbance (seeing flashing lights – the “scintillating scotoma”) or any other neurological symptom. The headache itself may be accompanied by nausea or vomiting. Patients with migraines may find relief in anti-inflammatory medications, triptans such as Sumatriptan etc., or may require a different approach in selected cases such as botox injections at periodic intervals.
Tension headaches are considered to be the most common headaches in adults and are characteristically described as “band-like” with the pain resulting in a pressure like sensation bilaterally around the head, as if one were wearing a headband. Unlike migraine headaches, tension headaches are usually not aggravated by loud sounds or bright lights or associated with an aura (pre-headache sensation) or other neurological symptom such as blurring of the eyes. These headaches are believe to occur more in women than in men, unlike cluster headaches, and may either be episodic with less than 15 episodes/month or chronic occurring more frequently during any given month.
Cluster headaches usually present with a sharp stabbing like pain in or around the eye area. These kind of headaches are more common in men and their name is derived from the fact that episodes occur in clusters i.e. patients will experience 1-3 episodes/day over a period of two weeks to 3 months (episodes are clustered together.) There is often a seasonal occurence of cluster headaches, with episodes occurring during the same time of the year in patients (often the spring or autumn) and due to the frequent occurence of eye redness and a runny nose (rhinorrhea) they are often mistaken for allergies. Unlike other types of headaches, cluster headaches have demonstrated a response to oxygen therapy.
Giant Cell (Temporal) Arteritis
Giant cell or temporal arteritis is a type of vasculitis (inflammation of the blood vessels) which involves the large blood vessels in the head (temporal artery.) This type of vasculitis often presents with a sharp pain which occurs over a background of a dull throbbing pain in the temporal are of the head (side of the head.) Giant cell arteritis if often accompanied by the sensation of tenderness in the scalp, pain in your jaw (jaw claudication,) and visual disturbances such as blurred or double vision. Due to the systemic nature of the vusulitides, you may also experience constitutional symptoms such as fever or weight loss. Left untreated, Giant Cell Arteritis may lead to permanent blindness and therefore it is of extreme importance that you visit the emergency department as soon as possible if you may be experiencing the symptoms if Giant Cell Arteritis, in which you will need to receive treatment with corticosteroids to damper the inflammatory reaction and prevent the development of loss of vision.
Headaches due to Intracranial Neoplasms (Tumors)
When are tumors responsible for headaches? Tumors result in a n increase in intracranial pressure (pressure within your skull) and therefore result in a variety of symptoms related to these effects. These include vomiting which is characteristically projectile, blurring of vision due to papilledema (optic disc swelling,) or other symptoms related to compression of nearby structures and nerves (double vision, etc.) Patients with headaches due to intracranial tumors often report the headache to awaken them from sleep or be more severe in the early morning hours. The pain may be difficult to characterize, described as dull and aching, or similar to a tension headache (band-like) or migraine.
Subarachnoid hemorrhages cause a severe headache of sudden onset known as a “thunderclap” headache. Patients often describe the headache as being the “worst headache of my life.” The headache may also be associated with fever, neck stiffness due to irritation of the meninges, and nausea and vomiting. Subarachnoid hemorrhages are usually due to rupture of an aneurysm at the base of the brain and may be seen in elderly patients with hypertension or connective tissue disease, although that may not always be the case (may occur at any age.) These headaches may be fatal if not accurately diagnosed in a timely fashion, so that urgent intervention can be undertaken. An extremely severe headache should prompt immediate emergency assessment, in which case a CT scan of the head may be performed to rule out hemorrhage in the subarachnoid space.
How are Headaches Diagnosed
Primary headaches (migraine, cluster, and tension) are usually diagnosed clinically i.e. by history and physical examination alone. The characteristic presentation for each may allow a diagnosis to be made and treatment initiated with no further workup. However, a severe headache of sudden onset “thunderclap headache” may be due to a subarachnoid hemorrhage, in which case your physician may perform a CT scan of the head looking for bleeding in the subarachnoid space. This test does not always detect SAH, and a lumbar puncture performed by inserting a needle into your back to analyze the cerebrospinal fluid (fluid which cushions your brain) may be required. In the case of suspicion of brain tumors, the CT scan (with contrast) or MRI of the brain may show the mass and its effects on the surrounding tissue (displacement of the midline due to pressure from the tumor, hemorrhage within the tumor etc.) The best initial test for giant cell arteritis would be an ESR as a marker of inflammation. Due to the potential for the development of blindness, an elevated ESR in a patient presenting with a headache which resembles giant cell arteritis is an indication to start treatment. The definitive diagnosis may require a biopsy (sample) to be taken from the temporal artery.
 Abu”Arafeh I, Razak S, Sivaraman B, Graham C. Prevalence of headache and migraine in children and adolescents: a systematic review of population”based studies. Dev Med Child Neurol 2010;52:1088–97.
In conclusion, headaches may be benign or indicate a more ominous underlying pathology. If you suffer from recurrent headaches, it would be prudent to recognize what type of headache you may have in order to communicate your symptoms more efficiently to your physician, or in order to seek emergency medical assistance to prevent possible complications or even potentially fatal outcomes.
The content published on this website is not intended to be an alternative to medical advice, recommendations, or management by your attending physician. Correct medical management requires thorough history, examination, and investigations, all of which can not be substituted by online resources.