Headache - Symptom Evaluation

About

The cause of headache is usually obvious from the description of the headache and the associated features.

Headache is one of the most common symptoms suffered by people world over. Though headaches are usually harmless and disappear with painkillers, in rare cases, they could be due to a serious condition like a brain tumor, meningitis or a bleed within the brain. A good history elicited by the doctor and a complete physical examination usually helps to diagnose the cause of pain. Tests are required to confirm the diagnosis in some cases.

Headaches may be acute, that is, of recent onset, or chronic, that is, present over a long duration. Some features that could help in the diagnosis of the type or cause of headache are:

• New, acute and very severe headaches, progressive headaches and headaches associated with neurological problems on examination could herald a serious issue and should be investigated in detail.
• Headache with high blood pressure in a pregnant woman may suggest preeclampsia.
• An episodic headache with a high blood pressure, palpitations and sweats could be due to pheochromocytoma or tumor of the adrenal gland.
• A severe headache with fever and neck stiffness may suggest meningitis.
• Headaches of longer duration and of similar intensity are likely to be benign.
• Pain on one side of the head may be migraine or cluster headache. Migraine is a throbbing type of headache more common in women and runs in families. Cluster headache affects one side of the head usually near the eye. It is more common in men and does not run in families. People with migraine may report associated symptoms like nausea and vomiting. It may appear just before menses in women.

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• A sense of tightness or pressure may be suggestive of tension-type headache. A sharp pain may be nerve related.
• Headache with pain over the sinuses of the face is suggestive of sinusitis.
• The type of headache may also be determined based on the factors that precipitate an attack. For example, a headache may follow a trauma or an episode of sinusitis. A migraine attack may be precipitated by emotional stress, fatigue, certain foods or menstruation. Cluster headache may be precipitated by alcohol. Headache with a change of position may suggest brain tumor.
• The time of appearance of the headache may help to diagnose the type of headache. For example, tension-type headaches are worse following stress or at the end of the day. Cluster headaches usually occur at the same time of the day or night. Hypnic headaches appear just as a person falls asleep.

A headache is usually diagnosed based on the symptoms. In some cases, tests may be necessary to rule out a serious condition. Imaging tests like CT scan and MRI are usually used in such cases. A lumbar puncture may be done to diagnose an infection or a bleed. An angiography may be necessary to rule out abnormalities in blood vessels.

Types

Headaches may be primary with no apparent cause or secondary where the cause of the headache is known.

Headaches may be primary or secondary. A brief description of various types of headaches is provided below:

Primary headache: Primary headaches are those headaches without any apparent cause. These include:

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• Migraine: Migraine is a throbbing type of headache that usually affects one side of the head. It affects women more commonly than men. An attack of migraine is associated with an increased sensitivity to light, sound or movement and may be accompanied by nausea or vomiting. It may be triggered by bright lights, sounds, hunger, alcohol, stress, physical exertion, lack or excess sleep, stormy weather, pressure changes, certain foods and hormonal fluctuations such as during menses.
• Tension-type headache: Tension-type headaches are constant headaches that are tightened and are usually generalized but more intense near the neck or back of the head. The patient may complain of tenderness of the head and poor concentration. This type of headache is often misdiagnosed as migraine.
• Cluster headache: Cluster headache affects men more commonly than women. The patient suffers from severe unilateral pain, usually located near one eye. It may be accompanied by features like redness and tearing of the eye, and nasal congestion and running of nose. Cluster headache may result in a neurological problem referred to as Horner’s syndrome. Horner’s syndrome is characterized by drooping of an eyelid, narrowing of the pupil of the eye and reduced sweating of one side of the face.
• Other headaches with autonomic symptoms: Besides cluster headache, headaches like paroxysmal hemicranias, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), and probable trigeminal autonomic cephalalgia also result in symptoms like tearing and redness of eyes and nasal congestion. The headaches are usually short lasting. These patients should undergo pituitary imaging studies and pituitary function tests to rule out pituitary tumors (The pituitary is a small gland in the head that secretes important hormones).
• Other primary headaches: These include:
• Primary stabbing headache: The headache feels like a stabbing pain in the head and face area. It may appear as a single stab or a series of stabs and lasts from one second to a few minutes.
• Primary cough headache: This type of headache is precipitated by cough and lasts for a few minutes or less. It may be associated with some malformations or tumors of the brain and hence, the patient should undergo imaging tests like CT and MRI, which should be repeated annually.
• Primary exertional headache: This is a pulsatile type of headache that follows exercise. It lasts for 5 minutes to a day and is usually affects both sides of the head.

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• Primary sex headache: Headache associated with sexual activity may appear in three forms - a dull ache in the head and neck that worsens with sexual activity, an explosive type of headache that occurs during orgasm, or a headache that develops after coitus. This type of headache often subsides within 6 months. Some cases may be associated with a bleed near the brain called subarachnoid hemorrhage, which should be ruled out in these patients.
• Hypnic headache: Hypnic headache is a type of headache that appears soon after a person falls asleep. The headache may reappear up to three times during the night. This headache usually affects females over the age of 60 years.
• Primary thunderclap headache: This type of headache appears as a sudden, severe headache in the absence of any provocation. Such headaches warrant detailed investigations to rule out serious conditions like a bleed or a clot in the brain, or a tumor of the adrenal gland called pheochromocytoma. Imaging techniques like CT scan and MRI, and lumbar puncture are necessary investigations in these cases.
• Hemicrania continua: Hemicrania continua is a headache similar to cluster headache with associated features like tearing and redness of eyes and nasal congestion. However, unlike cluster headache, this type of headache is usually continuous.
• New daily-persistent headache (NDPH): This type of headache may resemble migraine, but the patient is usually headache free at the end of two years.

  Secondary Headaches: These are headaches usually as a result of another disease or condition. The primary cause may be obvious in some cases.  Secondary Headaches Include:

• Headache attributed to head and/or neck trauma: Post-traumatic headache usually appears within a day or so after injury, worsens over the next few days and then subsides. It may be accompanied by nausea, vomiting or visual disturbances. Other neurological problems like problems with balance, impairment of memory, poor concentration, emotional instability and increased irritability may accompany the headache. A CT or MRI scan usually does not show any abnormality.
• Headache due to a disorder in the blood vessels: This type of headache may be caused by:
• A clot in the blood vessels leading to stroke
• A bleed in the brain
• An abnormality of blood vessels in the brain
• Inflammation of arteries in head and neck

The type of headache varies according to the cause. For example, an acute, severe headache with a stiff neck but without fever may suggest a subarachnoid hemorrhage (a bleed just below the tissue covering the brain). Headache due to inflammation of blood vessels, referred to as giant cell arteritis, can cause one-sided headache, with non-specific symptoms like muscle aches, loss of appetite, weight loss and sometimes loss of vision.

• Headache due to non-vascular intracranial disorder: These include headaches due to tumors, seizures, post lumbar puncture and other conditions.  The headache seen in brain tumors may be deep, dull-aching type of moderate intensity. It may worsen with exertion or change of position and may be associated with nausea and vomiting. It may affect sleep in some cases. Headache following a seizure usually develops within 3 hours of the seizure and subsides within 72 hours.
• Headache due to a substance or its withdrawal: Use or withdrawal of drugs and substances like alcohol, carbon monoxide, nitrates, cocaine, cannabis, and monosodium glutamate can cause headaches. Overuse of certain medications like ergotamine, triptans, and painkillers including opioids can also result in headache. A history elicited from the patient regarding the use of these substances and medications can help to diagnose the condition. 
• Headache due to infection: A headache may arise due to meningitis or inflammation of the coverings of the brain, encephalitis of inflammation of the brain, a brain abscess, or a general infection of the body. The headache in meningitis is acute, severe and pounding, with fever and a stiff neck. Nausea and vomiting are also present. A lumbar puncture helps in the diagnosis. An infection affecting the general body can also cause headache, which is relieved following treatment of the infection.
• Headache due to disorder of homoeostasis: A headache can be caused by disordered homeostasis of the body like reduced oxygen or an increase in carbon dioxide levels as seen at high altitudes, fasting, high blood pressure and hypothyroidism. Heart disease like angina can also result in headache, in which case the headache is associated with exercise.
• Other causes of headache: Headache or facial pain may occur due to disorders of
• Skull bone like metastasis and Paget’s disease
• Neck like torticollis and cervical spondylosis
• Eyes like eyestrain, glaucoma, squint or inflammatory disorders of the eye. In glaucoma, the eye may be red and associated with visual disturbances
• Ears like ear infection
• Nose and sinuses like rhinosinusitis. The headache is usually located in the frontal area of the head or over the sinuses
• Teeth, mouth or other facial or cranial structures

The underlying disorder is usually obvious in these conditions. The headache disappears when the underlying disorder is treated.

• Headache due to psychiatric disorder: In some cases, a headache may be to an underlying psychiatric disorder like anxiety and depression.

FAQs

1. Which doctor should I visit in case I suffer from headache?

You should visit your family doctor / general practitioner to treat headache. He may refer you to a neurologist if required.

2. What tests are used to diagnose headaches?

Usually, headaches are diagnosed based on description of symptoms and do not require the patient to undergo any tests. However, if the doctor suspects something serious and wants to rule it out, he may advise imaging tests like CT scan or MRI to look for any pathology. A lumbar puncture may also be advised to diagnose infections or bleeding in the central nervous system. An angiography may be necessary to study the blood vessels supplying to the head region.

3. Are there any over-the-counter medications for the treatment of headache?

Headache can be often treated with an aspirin-like painkiller available over-the-counter. In cases like migraine, specific drugs are needed which are available on prescription.