Being a pain management doctor, I often see patients with headaches at my practice. I get asked two questions most often: “Is it a migraine?” And “Could this be something serious, like a brain tumor?” The good news is, most headaches are not a brain tumor and are not serious. There are quite a few different types of headaches, and it’s important to see a physician competent in the diagnosis and treatment of headaches so that you can obtain maximal relief. In this blog we’ll go over some of the different types of headaches, the fact that not all headaches or migraines, and certainly not all headaches are brain tumors, as again, brain tumors are very rare, and patients should rest assured that that’s not likely the cause of their headache.
Depending on the time of year, patients can experience allergy headaches. The symptoms of an allergy headache are typically generalized headaches, not on any particular side of the head or brain, and they sometimes experience nasal congestion, sneezing, and watery eyes. These are usually seen during changes in the seasons, when pollen and mold levels are higher. Allergies to foods, though, typically don’t cause allergic headaches.
The treatments for allergy headaches are antihistamine medications as well as topical and nasal cortisone related sprays or desensitization injections.
One of the more common headaches is a caffeine withdrawal headache. The symptoms associated with this type of headache typically is a throbbing sensation, caused by rebound dilation of the blood vessels, and they occur multiple days after consumption of large quantities of caffeine. This can also occur if you stop drinking caffeine and you’re a regular coffee drinker. The treatment is actually terminating caffeine consumption and that can cause you to have a few days of headaches. Eventually, caffeine withdrawal headaches will go away if you discontinue caffeine completely.
Another type of headache is called a cervicogenic headache. We also refer to these as arthritis headaches, and these often are in the back of the head or neck and intensify with movement. They can be caused by a variety of issues including arthritis in the neck or inflammation of the blood vessels of the head. The precipitating factors are unknown. These headaches are frequently treated with anti-inflammatory medications and muscle relaxants. However, they can also be treated with interventional procedures in the neck such as radiofrequency ablations to destroy the sensory nerves causing these headaches.
Chronic daily headaches are a broad range of headache disorders that occur more than 15 days per month. They are broken down into several categories. The precipitating factors typically evolve from what’s called a transformed migraine, although they’re not related to tension-type headaches. They can evolve from episodic tension-type headaches and they can also be associated with chronic medication or headache.
The treatment of chronic daily headaches depends on the type of headache and multiple medication options do exist. The chronic migraine headache is a headache that also occurs more than 15 days a month for more than three months. The headaches typically last for at least six to eight hours at a time, but don’t always have to. The features of migraines are often associated with medication overuse and we call that medication overuse headache or rebound headaches. But they can also occur without medication overuse and be associated with major life events, obesity, as well as stress and changes in one’s blood pressure.
A serious cause of headache could be a brain aneurysm. Much like brain tumors, these are quite rare. The thing about aneurysm headaches is they may mimic frequent migraine or cluster headaches and they feel painful, but in a particular area of the brain. Oftentimes this is behind the eye. Depending on where the aneurysm is located, the pain can be reported as unbearable and can be associated with double vision and a rigid, stiff neck.
When an aneurysm bursts or ruptures, this is an emergency that can be life-threatening. Therefore, this type of headache is another reason why headaches should be worked up by someone like an interventional pain management physician who’s trained in the diagnosis and treatment of headaches. Aneurysm headaches can have precipitating factors such as a congenital tendency or extreme hypertension. If an aneurysm is discovered early, it’s either watched or treated with surgery.
The way to prevent aneurysm headaches is to keep blood pressure under control. This is why it’s important to have a primary care physician who’s visited at least on an annual basis.
Another type of headache is a cluster headache. Cluster headaches are less common than migraines and they’re described as excruciating pain in the vicinity of the eyes and they’re often associated with tearing of the eyes, nose congestion, and flushing of the face. This type of headache frequently develops during sleep and will wake patients, and the headaches can last for several hours.
Attacks typically occur every day for weeks or even months, then disappear for up to a year. 80% of cluster headache patients are male, most between the ages of 20 and 50. Precipitating factors for cluster headaches can include alcoholic beverages as well as excessive smoking. Much like migraines, cluster headaches are treated with triptan agents such as sumatriptan, or intranasal application of local anesthetic agents and oxygen. Cluster headaches can be prevented by cutting down on excessive drinking and smoking and also, in some patients, by using a small dose of steroids on a daily basis. Ergotamine and calcium channel blockers are also a medication that is used for cluster headaches. More severe ones can be treated with lithium.
Depression can be a cause of headaches. People with painful diseases tend to become depressed and this can precipitate depression-type headaches. Depression type headaches can be prevented by treating the underlying depression with medications such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, or monoamine oxidase inhibitors (MAOIs).
Eye strain headaches are fairly common with those who work on computers all day long. They’re usually described as frontal and bilateral (occurring on both sides) and they’re related to eye strain. Precipitating factors could be muscle imbalances in the eyes or uncorrected vision such as astigmatism. The treatment for this type of headache is a correction of the vision and making sure you’re using the proper glasses.
Exertional headaches are another type of headache. These typically have a short duration, up to an hour, and they follow physical exertion such as running, jumping, or even sexual intercourse or passive exertion such as sneezing or coughing. Precipitating factors can be aneurysms, tumors, or blood vessel malformation. About 90% of exertional headaches are related to migraine or cluster headaches. There’s often an overlap. The treatment of exertional headaches requires an appropriate diagnosis and these headaches are commonly treated with indomethacin or propranolol.
Extensive testing is usually part of the workup to determine the headache cause especially if an exertional headache is suspected as it’s not as clear of a diagnosis as some of the other headaches.
These are typically mild-moderate frontal location headaches. They are non-pulsating and caused by fasting. These headaches are cured quite easily by getting well-hydrated and eating. Typically putting some sugars in the body with hydration will get rid of a fasting headache.
There are hangover headaches which have migraine-like symptoms of throbbing pain and nausea, but typically not located to one side. These headaches, of course, are caused by alcohol. Some of you may recall waking up in the middle of the night or the next day after drinking and having these types of headaches.
We treat these headaches with clear liquids and consumption of fructose such as honey or tomato juice. The prevention is to drink alcohol only in moderation and stay extremely well hydrated with water while you’re drinking alcohol.
There is a type of migraine called a hemiplegic migraine that can be quite worrisome but is actually relatively benign. A patient having these will experience stroke-like symptoms with severe throbbing pain and it’s often on one side of the head. It’s associated with numbness, weakness or paralysis on one side of the body.
There can also be nausea and vomiting as well as dizziness, loss of balance and speech difficulties as well as visual disturbances and auras, sensitivity to light, sound, and smell. So this does sound a lot like a migraine headache, but the difference is that there are the stroke-like symptoms that are associated with it. These types of headaches tend to have a strong genetic component. Hemiplegic migraines often are treated with significant dietary modifications, as there are many triggers that we find in the workup of how many hemiplegic migraines that are related to one’s diet.
Medications such as topiramate, valproic acid, and calcium channel blockers have had the best pharmacological results with hemiplegic migraines. We can also treat these with preventative medications.
Hypertension headaches are another type of headache that are described as generalized or with a hairband type of path that’s most severe in the morning and diminishes throughout the day. These are typically associated with severe hypertension, over 200 diastolic, and 110 diastolic. Again, this is another important reason to see your primary care doctor and make sure, if you do have underlying hypertension, that it is treated. Keep that blood pressure under control!
Females of menstruation age can experience menstrual headaches, and these are very much like migraines. They can occur shortly before, during, or immediately after menstruation or mid-cycle. Precipitating factors have to do with variances in the estrogen level. These are usually treated with biofeedback, ergotamine, dihydroergotamine, or a 5 HT agonist medication.
New daily persistent headache is a newer diagnosis of headache, best described as the rapid development, usually in less than three days of an unrelenting headache that doesn’t go away. The patients typically present for the first time with no past history of headaches. These do not evolve from migraine or episodic tension-type headaches. They are a new headache and may be the result of a viral infection. These can resolve on their own within several months and can be very difficult to treat.
There can also be post-traumatic headaches. These are localized or generalized pain that can mimic a migraine or tension-type headache. And they usually occur on a daily basis following trauma to the head. Treatment of these headaches is typically beta-blockers, biofeedback and anti-inflammatory medication.
Sinus headaches are another type of headache that generally occurs over the sinus areas. These can be treated with medications including decongestants and antibiotics, and sometimes surgical drainage if necessary. Some patients get headaches related to temporomandibular joint dysfunction or a poor bite. These are treated with relaxation, biofeedback, and sometimes the use of a bite plate. In extreme cases, the correction of malocclusion may be necessary surgically, but it’s not often recommended.
Tension headaches are described as dull with non-throbbing pain, are frequently bilateral, and are associated with tightness in the scalp or neck. The degree of severity is relatively constant. These can be brought on by emotional stress or hidden depression. We treat these with aspirin, acetaminophen, other anti-inflammatories, caffeine, ice packs, muscle relaxants, antidepressants, and biofeedback. These are prevented by avoiding stress.
Trigeminal neuralgia is a rare but very painful type of headache. It’s also known as a tic douloureux headache. Symptoms are short jabbing-like pain, and trigger areas are found in the face around the mouth or jaw, and can be relatively disturbing to one’s life due to how severe these headaches are. It’s a disease of the neural impulses. It’s more common in women over age 55. We don’t know what causes these. Treatments are typically anticonvulsants and muscle relaxants – and on rare occasions, ablation of a nerve with neurosurgery.
On rare occasions, patients will have a tumor and those can cause headaches. Those headaches are typically characterized by pain that progressively worsens, with projectile vomiting possible and disturbances of speech and possibly even personality. Patients with tumor headaches often report problems with balance or equilibrium, and may actually present for the first time with a seizure.
It’s very important to get MRIs on the initial workup on patients with headaches to make sure that they don’t have a serious cause of headaches such as tumors.
Its symptoms are severe and sudden, and they may be accompanied also by nausea, vomiting, fever, seizures, speech problems, weakness, confusion, and visual disturbances. In fact, these headaches can also mimic a stroke. Thunderclap headaches are usually not dangerous. They’re benign and not life-threatening. As for the treatment of thunderclap headaches, the nature of the headache by itself cannot allow the distinction between benign and serious causes. So it’s really important to get treatment by a board-certified physician who’s qualified to appropriately diagnose and treat headaches.
The takeaway is that it’s important for patients with headaches to have them properly diagnosed. Once they have an appropriate diagnosis, a treatment plan can be established.
