headache

A headache is a condition of mild to severe pain in the head; sometimes upper back or neck pain may also be interpreted as a headache.


Headache is defined as pain in the head that is located above the eyes or theears, behind the head (occipital), or in the back of the upper neck. Headache, like chest pain or dizziness, has many causes.

Headaches are one of the most common health complaints. Most headaches that occur without other symptoms will respond well to self-care. Most headaches are caused by tension and respond well to prevention and home treatment.

Headaches have a wide variety of causes, ranging from eyestrain to inflammation of the sinus cavities to life-threatening conditions such as encephalitis, brain cancer, meningitis, and cerebral aneurysms. When the headache occurs in conjunction with a head injury the cause is usually quite evident; however, many causes of headaches are more elusive. The most common type of headache is a tension headache. Some people experience headaches when they are hungry or dehydrated.
It is common to take over-the-counter painkillers such as aspirin or acetaminophen (sold as Tylenol or Panadol) to relieve headaches.

Types of Headache

• Tension headache
• Migraine
• Cluster headache
• Rebound headaches
• Ictal headache
• Ice cream / Brain Freeze headache
• Thunderclap headache
• Vascular headache

Tension Headache

• Tension headaches, which were recently renamed tension type headaches by the International Headache Society, are the most common type of headaches. The pain can radiate from the neck, back, eyes, or other muscle groups in the body. Nearly everyone will have at least one tension headache in their lifetime.
• Frequency and duration - Tension headaches can be episodic or chronic. Episodic tension headaches are defined as tension headaches occurring less than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months. Tension headaches can last from minutes to days or even months, though a typical tension headache lasts 4-6 hours.
• Pain - Tension headache pain is often described as a constant pressure, as if the head were being squeezed in a vise. The pain is frequently bilateral which means it is present on both sides of the head at once. Tension headache pain is typically mild to moderate, but may be severe. In contrast to migraine, the pain does not increase during exercise.
• Cause - The exact cause of tension headaches is still unknown. It has long been believed that they are caused by muscle tension around the head and neck. However although muscle tension may be involved, there are many forms of tension headaches and some scientists now believe there is not one single cause for this type of headache. One of the theories is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information, for example from the temporal muscle or other muscles, and interprets this signal as pain. One of the main molecules which is probably involved is serotonin. Evidence for this theory comes from the fact that tension headaches may be successfully treated with certain antidepressants. Another theory says that the main cause for tension type headaches and migraine is teeth clenching which causes a chronic contraction of the temporalis muscle.
• Treatment - Episodic tension headaches generally respond well to over-the-counter analgesics, such as acetaminophen or aspirin. However, these medications should be avoided in cases of chronic tension headache, due to the risk of rebound headaches. Chronic tension headaches are more difficult to treat.
• Suggested therapies include :
  • Swimming two to three times a week
  • Acupuncture
  • Biofeedback
  • Massage
  • Heat Pillow
• Tension headaches are exacerbated by states or activities that induce muscle tension, such as stress. Avoiding such states can lessen the frequency of tension headaches. Tension headaches can also be secondary to other conditions, such as an upper respiratory infection or other virus.
• Often the best treatment for a mild tension headache that does not impair a person's ability to function is simple endurance. Many tension headache sufferers receive relief from sleep. However, it is always best to see your physician for a full work-up of the headaches.
• Prognosis - Tension headaches that do not occur as a symptom of another condition are painful and annoying, but not harmful. It is usually possible to receive relief from treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated.

Migraine Headache

• Migraine is a form of headache, usually very intense and disabling. It is a neurologic disease of neuronal origin. The word "migraine" comes from the Greek construction hemikranion (pain affecting one side of the head)
• Symptoms - Migraine is characterized by attacks of moderate or severe pain and must include one of the following:
  • pain on only one side of the head, nausea, vomiting, photophobia and phonophobia,
  • or pain worst with movement.
• The symptoms and their timing vary considerably among migraine sufferers, and to a lesser extent from one migraine attack to the next. Migraine had been thought to be caused by vasodilation in the head and neck, however newer research suggests the cause of the pain itself is from activation of the trigeminal nerve. The trigger of the migraine may be overactivity of nerve cells in certain areas of the brain (for example, the raphe nucleus). Dilation of the blood vessels is now known to be caused from chemicals released from nerve terminals and inflammatory cells.
• Classical migraine or migraine with aura is preceded by a group of specific symptoms called aura, most commonly experienced as a visual disturbance. Common migraine or migraine without aura, in contrast, lacks this specific warning. Many migraine patients will experience a prodrome, a vague sensation that things are just not right that may precede the headache by several hours. Some experience aura without migraine, a condition formerly called amigrainous migraine and usually called acephalic migraine. Although sometimes comparable in severity, the symptoms of migraine differ from those of cluster headache.
• The most common aura preceding a migraine attack is a multicolored zig-zag pattern which grows from a small dot until it covers a large part of the left or right visual field of both eyes. The aura must last less than 60 minutes and the headache must begin sometime after the start of the aura until 60 minutes from the end of the aura. Auras can be any specific neurological symptom complex and some experience tingling sensations called paresthesias or disturbances of other regions of the brain (such as language ability or smell) instead of a visual aura, either as an occasional alternate or their normal aura.
• Migraine can accompany, in many cases, another type of headache called tension headache. Studies have demonstrated in those patients that get both migraine and tension type headaches, that their tension headaches will respond to their usual migraine treatment. This is in contrast to patients who only get tension type headaches. Migraines can be associated with seizures. Stroke symptoms are seen in some patients and are known as complicated migraine. These symptoms should not be permanent.
• Migraine often runs in families and starts in adolescence, although some research indicates that it can start in early childhood or even in utero. Migraine occurs more frequently in women than men, and is most common between ages 15-45, with the frequency of attacks declining with age in most cases

Treatment - Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs.

Elimination of triggers - In a minority of patients the incidence of migraine can be reduced through dietary changes to avoid certain chemicals present in such foods as cheddar cheese, chocolate, nuts and most alcoholic beverages. Some triggers (for example, hunger or stress) may be situational and can be avoided through lifestyle changes. However, other triggers such as particular points in the menstrual cycle or certain weather patterns are impossible or impractical to avoid.

Avoid bright flashing lights if you notice these trigger attacks; most migraineurs are sensitive and avoid bright or flickering lights. Relaxation after stress, notably weekends and holidays, is a potent trigger; wind down gradually if possible.

Symptomatic control to abort attacks - For patients who have been diagnosed with recurring migraines, doctors recommend taking painkillers to treat the attack as soon as possible. Many patients avoid taking their medications when an attack is beginning, hoping that "it will go away". However in many cases once an attack is underway, it can become intensely painful, last for a long time, and become somewhat resistant to medical treatment. In contrast, treating the attack at the onset can often abort it before it becomes serious, and can reduce the frequency of subsequent attacks in the near-term.

The first line of treatment is over-the-counter medications. Doctors start patients off with simple analgesics, such as paracetamol (acetaminophen), aspirin and caffeine. They may provide some relief, although they are not effective for most sufferers.

Narcotic pain killers (for example, codeine, morphine or other opiates) provide variable relief, but their side effects and high risk of addiction contraindicates their general use.

If over-the-counter medications do not work, the next step for many doctors is to prescribe fioricet or fiorinal, which is a combination of butalbital (a barbituate), acetaminophen (in fioricet) or acetylsalicylic acid (in fiorinal), and caffeine. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to rebound headaches.

Anti-emetics by suppository or injection may be needed in cases where vomiting dominates the symptoms. The earlier these drugs are taken in the attack, the better their effect.

Until the introduction of sumatriptan (Imitrex®/Imigran®) around 1985, ergot derivatives were the primary oral drugs available to abort a migraine once it is underway. However, ergotamine tablets (usually with caffeine), though sometimes effective, have fallen out of favour. Absorption is erratic unless taken by suppository or injection. Dihydroergotamine (DHE), which must be injected or inhaled, can also be effective. These drugs can be used either as a preventive or abortive therapy.

Sumatriptan and related serotonin agonists are now the therapy of choice for severe migraine attacks that cannot be controlled by other means. They are highly effective, reducing the symptoms or aborting the attack within 30 to 90 minutes in 70-80% of patients. Some patients have a rebound migraine later in the day, and only one such rebound in a day can be treated with a second dose of a triptan. They have few side effects if used in correct dosage and frequency. Some members of this family of drugs are:

• sumatriptan (Imitrex®, Imigran®)
• zolmitriptan (Zomig®)
• naratriptan (Amerge®, Naramig®)
• rizatriptan (Maxalt®)
• eletriptan (Relpax®)
• frovatriptan (Frova®)
• almotriptan (Almogran®)

Evidence is accumulating that these drugs are effective because they act on serotonin receptors on the nerve endings as well as the blood vessels. This leads to a decrease in the release of a several peptides including CGRP, Substance P, among others.

These drugs are available only by prescription (US and UK). Many migraine sufferers do not use them only because they have not sought treatment from a physician.

Preventive drugs - It is critically important that patients who have more than 2 headaches days per week be placed on preventatives and avoid overuse of acute pain medications.

Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. It is used only if attacks occur more often than every two weeks. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next.

The most effective prescription medications include several classes of medications including Beta blockers such as propranolol and atenolol, Antidepressants such as amitriptyline, and anticonvulsants such as valproic acid and topiramate.

Migraine sufferers usually develop their own coping mechanisms for intractable pain. A cold or hot shower directed at the head, less often a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients, but both should be used when needed.

Alternative approaches - Some migraine sufferers find relief through acupuncture which is usually used to help prevent headaches from developing. Sometimes acupuncture is used to relieve the pain of an active migraine headache. In the only controlled trial of acupuncture with a sham control in migraine, the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.

Biofeedback has been used successfully by some to control migraine symptoms through training and practice.

Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines.

The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks. Clinical trials have been carried out, and appear to confirm that the effect is genuine (though it does not completely prevent attacks).

Kudzu root (Pueraria lobata) has been demonstrated to help with menstrual migraine headaches and cluster headaches. While the studies on menstrual migraine assumed that kudzu acted by imitating estrogen, it has since been shown that kudzu has significant effects on the serotonin receptors.

Diet, visualization, and self-hypnosis are also important alternative treatment and prevention approaches.

Cluster Headache

• Cluster headaches are rare headaches that occur in groups or clusters. Cluster headache sufferers typically experience very severe headaches of a piercing quality near one eye or temple that last for between 15 minutes and three hours. Cluster headaches are frequently associated with drooping eyelids, red, watery eyes, and nasal congestion on the affected side of the face. The headaches are unilateral and occasionally change sides. The neck is often stiff or tender in association with cluster headaches, and jaw and teeth pain is sometimes reported.
• In episodic cluster headache, these headaches occur once or more daily, often at the same times each day, for a period of several weeks, followed by a headache-free period lasting weeks, months, or even years. Approximately 10-15% of cluster headache sufferers are chronic; they can experience multiple headaches every day for years. Cluster headaches are occasionally referred to as "alarm clock headaches", as they can occur at night and wake a person from sleep. Other synonyms for cluster headache include Horton's syndrome and "suicide headaches" (a reference to the excruciating pain and resulting desperation).
• The location and type of pain has been compared to a 'brain-freeze' headache from rapidly eating ice cream; this analogy is limited, but may offer some insight into the cluster headache experience. Persons who have experienced both cluster headaches and other painful conditions (childbirth, migraines) report that the pain of cluster headaches is far worse. During a cluster headache attack, a person often alternates between pacing and laying still. Sensitivity to light is more typical of a migraine, as is vomiting, but they can be present in some sufferers of cluster headache.
• Whereas other headaches, such as migraines occur more often in women, cluster headaches occur in men at a rate 2.5 to 3 times greater than in women. Between 1 and 4 people per thousand experience cluster headaches in the U.S. and Western Europe; statistics for other parts of the world are fragmentary. Latitude plays a role in the occurrence of cluster headaches, which are more common as one moves away from the equator towards the poles. It is believed that greater changes in day length are responsible for the increase.
• While the immediate cause of pain is in the trigeminal nerve, the true cause(s) of cluster headache is complex and not fully understood. Among the most widely accepted theories is that cluster headaches are due to an abnormality in the hypothalamus. This can explain why cluster headaches frequently strike around the same time each day, and during a particular season, as one of the functions the hypothalamus performs is regulation of the biological clock. Certain immune dysfunctions and metabolic abnormalities have also been reported in patients. There is a genetic component to cluster headaches, although no single gene has been identified as the cause. As a group, cluster headache patients are more likely to have suffered brain trauma than the general population. Sinus problems, damage to the jaw, and sleep apnea are also more common in cluster headache patients, but these factors do not adequately explain the disease.
• Treatment - Many doctors are unfamiliar with this disease, and cluster headaches often go undiagnosed for many years. Paroxysmal Hemicrania (PH) is a condition similar to cluster headache, but PH responds well to treatment with the anti-inflammatory drug indomethacin and the attacks are very much shorter, often lasting seconds only.
• Medically, cluster headaches are considered benign, but because of the extreme and often debilitating pain associated with them, a severe attack is nevertheless treated as a medical emergency by doctors who are familiar with the condition. Doctors who are less familiar with the disease may neglect sufferers in emergency rooms and force them to endure inordinate spans of time before receiving treatment, if any treatment at all is granted. Sometimes, sufferers of the disease may even be accused of drug seeking behavior.
• Even narcotics are mostly ineffective due to the intensity of the pain involved in cluster attacks. Anecdotal evidence indicates that cluster headaches, on occasion, can be so excruciating that even morphine does little to ease the pain. Usually, however, demerol is sufficient if used at the onset of pain.
• Over the counter pain medications (such as aspirin, acetaminophen, and ibuprofen) have no effect on the pain from a cluster headache. Some have reported partial relief from narcotic pain killers, but the frequency of their use in a cluster cycle (1-3 times a day) often disqualifies them from use. However, some newer medications like fentanyl have shown great promise in early studies and use.
• Medications to treat cluster headaches are classified as either abortives or prophylactics (preventatives). The most successful abortives include breathing pure oxygen (12-15 liters per minute in a non-rebreathing apparatus) and triptan drugs like sumatriptan and zolmitriptan. A wide variety of prophylactic medicines are in use, and patient response to these is highly variable. Preventitives include muscle relaxants, lithium, calcium channel blockers such as Verapimil, ergot compounds, anti-seizure medicines, and atypical anti-psychotics.
• Magnesium supplements have been shown to be of some benefit in about 40% of patients. Melatonin has also been reported to help some. Hot showers have helped about 15% of people who try it. Feverfew, a herb used to treat migraine, is not clearly beneficial according to anecdotes from web forums.
• There is substantial anecdotal evidence that psilocybin (mushrooms) and LSD may be able to abort cluster cycles. A clinical study under the auspices of MAPS is being developed at Harvard University.
• Nitroglycerin (glyceryl trinitrate) can sometimes induce cluster headache similar to spontaneous attacks. Alcohol is recognized as a common trigger of cluster headaches when a person is in cycle or susceptible. Hydrocarbons (petroleum solvents, perfume) are also recognized as a trigger for cluster headaches. Many patients have a decreased tolerance to heat, and this may act as a trigger in some. The role of diet and specific foods in triggering cluster headaches is controversial and not well understood.
• Some people with extreme headaches of this nature (especially if they are not unilateral) may actually have something else: an ictal headache. Anti-convulsant medications can significantly improve this condition, so make sure you talk with your doctor about this possibility if you think you might be affected.

Rebound Headache

• Rebound headaches occur when medication is taken too frequently to relieve headache pain. Rebound headaches frequently occur daily and can be very painful. A diagnosis of rebound headaches can be easy or difficult, as the cause is very easy to identify but very difficult to diagnose. Overuse of painkillers can be confirmed simply by asking the patient if his or her headaches assumed a new pattern or became more severe after taking painkillers excessively (generally classified as more than 3 times per week). However, the only way to make a certain diagnosis of rebound headache is to withdraw the patient from medication for anywhere up to 6 months. It should be noted that withdrawal from medication will actually intensify the headaches for the first few weeks. After this period, the headaches will gradually recede.
• Following treatment, many patients revert to their prior headache pattern. A physician should be consulted before re-use of medications.

Ictal headache

• Ictal headaches are headaches associated with seizure activity. They may occur either before (pre-ictal), after (post-ictal), or most rarely during a seizure. Many cases of ictal headache may be misdiagnosed as migraine with aura, or even cluster headache. However, whereas these conditions usually involve just one side of the head (are unilateral), an ictal headache may be centrally situated or cover the entirety of the head.
• Severity of ictal headaches can vary from a slight pressure or "cloud" to an intensity far beyond migraine. Some have called it a "suicide headache" in the worst instances. Temporary blindness may also occur in some cases.
• Ictal headaches can be controlled with anti-convulsant medications, in many cases.
• Note that other symptoms besides headache may be either present or absent, and may include unusual thoughts or experiences. In these cases it is especially important to obtain a correct diagnosis. Many people with these experiences are accidentally diagnosed with conditions such as psychosis or even schizophrenia and given anti-psychotic medications which ironically may increase seizure activity. An EEG is recommended to detect other signs of epilepsy in all cases, however even when this does not prove determinative, anti-convulsants may be a first line of treatment if these symptoms are present with headache.

Ice Cream / Brain freeze Headache

• Brain Freeze or ice cream headache are term used to describe a form of cranial pain or headache which human beings are known to sometimes experience after consuming cold beverages or foods such as ice cream, often as a result of consuming at a high rate of speed.
• In rare instances, neuro-cranial blood vessels can constrict so completely that a temporary blackout can occur.
• Mechanism/Cause - The reaction is triggered by the cold from the substance consumed coming into contact with the roof of the mouth while the individual eats it. It triggers nerves that give the brain the impression of a very cold environment. To return warmth to the brain, blood vessels start to swell, which causes the pain for, typically, around 30 seconds.
• It is reported that pain can be relieved by moving the tongue to the roof of the mouth, which will cause greater warmth in the region.

Thunderclap Headache

• A thunderclap headache is a sudden and severe headache, diagnosed via a process of exclusion with accompanying negative CT and lumbar puncture results.
• Thunderclap headaches can be indicative of life threatening medical problems. If one occurs in yourself or someone else then they must be taken to a hospital immediately. If no transportation is available or the condition is rapidly deteriorating then a call for help must be made.