Headache
Headache | |
---|---|
Other names | Cephalalgia |
, head or neck massage |
Headache, also known as cephalalgia, is the symptom of
Headaches can occur as a result of many conditions. There are a number of different classification systems for headaches. The most well-recognized is that of the
Treatment of a headache depends on the underlying cause, but commonly involves pain medication (especially in case of migraine or cluster headaches).[6] A headache is one of the most commonly experienced of all physical discomforts.[7]
About half of adults have a headache in a given year.[3] Tension headaches are the most common,[7] affecting about 1.6 billion people (21.8% of the population) followed by migraine headaches which affect about 848 million (11.7%).[8]
Causes
There are more than 200 types of headaches. Some are harmless and some are
Headaches are broadly classified as "primary" or "secondary".
Primary
Ninety percent of all headaches are primary headaches.[12] Primary headaches usually first start when people are between 20 and 40 years old.[13][14] The most common types of primary headaches are migraines and tension-type headaches.[14] They have different characteristics. Migraines typically present with pulsing head pain, nausea, photophobia (sensitivity to light) and phonophobia (sensitivity to sound).[15] Tension-type headaches usually present with non-pulsing "bandlike" pressure on both sides of the head, not accompanied by other symptoms.[16][17] Such kind of headaches may be further classified into-episodic and chronic tension type headaches[18] Other very rare types of primary headaches include:[11]
- 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 or occipital 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 causes (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: a moderate-severe headache that starts a few hours after falling asleep and lasts 15–30 minutes. The headache may recur several times during the night. Hypnic headaches are usually in older women. They may be treated with lithium.
Secondary
This section needs additional citations for verification. (February 2021) |
Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as
More serious causes of secondary headaches include the following:[11]
- 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): a headache that starts with eye pain, blurry vision, associated with nausea and vomiting. On physical exam, the person will have red eyes and a fixed, mid-dilated pupil.
- Post-ictal headaches: Headaches that happen after a convulsion or other type of seizure, as part of the period after the seizure (the post-ictalstate)
Migraine headaches are also associated with
Pathophysiology
The
Headaches often result from traction or irritation of the meninges and blood vessels.
Primary headaches are more difficult to understand than secondary headaches. The exact mechanisms which cause migraines, tension headaches and cluster headaches are not known.[28] There have been different hypotheses over time that attempt to explain what happens in the brain to cause these headaches.[29]
Migraines are currently thought to be caused by dysfunction of the nerves in the brain.
Currently, most specialists think migraines are due to a primary problem with the nerves in the brain.
People who are more susceptible to experiencing migraines without headaches are those who have a family history of migraines, women, and women who are experiencing hormonal changes or are taking
Diagnosis
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 the 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 NSAIDS
|
may exist with tension headache[40] |
Most headaches can be diagnosed by the clinical history alone.[11] If the symptoms described by the person sound dangerous, further testing with neuroimaging or lumbar puncture may be necessary. Electroencephalography (EEG) is not useful for headache diagnosis.[41]
The first step to diagnosing a headache is to determine if the headache is old or new.[42] A "new headache" can be a headache that has started recently, or a chronic headache that has changed character.[42] 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, they have a new headache.[citation needed]
Red flags
It can be challenging to differentiate between low-risk, benign headaches and high-risk, dangerous headaches since symptoms are often similar.[43] Headaches that are possibly dangerous require further lab tests and imaging to diagnose.[14]
The American College for Emergency Physicians published criteria for low-risk headaches. They are as follows:[44]
- 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 mean that a headache warrants further investigation with neuroimaging and lab tests.[14]
In general, people complaining of their "first" or "worst" headache warrant imaging and further workup.[14] 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.[43] People with neurological findings on exam, such as weakness, also need further workup.[43]
The American Headache Society recommends using "SSNOOP", a mnemonic to remember the red flags for identifying a secondary headache:[42]
- 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)
Other red flag symptoms include:[14][42][43][45]
Red Flag | Possible causes | The reason why a 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 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) | 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 |
Severe 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 | 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 | 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
Old headaches are usually primary headaches and are not dangerous. They are most often caused by
The mnemonic 'POUND' helps distinguish between migraines and tension-type headaches. POUND stands for:
- Pulsatile quality of headache
- One-day duration (four to 72 hours)
- Unilateral location
- Nausea or vomiting
- Disabling intensity[46]
One review article found that if 4–5 of the POUND characteristics are present, a migraine is 24 times as likely a diagnosis than a 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).[17] 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 a headache trigger, and cheese as a headache trigger.[47]
Temporomandibular jaw pain (chronic pain in the jaw joint), and cervicogenic headache (headache caused by pain in muscles of the neck) are also possible diagnoses.[42]
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. 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.[49]
Cephalalgiaphobia is fear of headaches or getting a headache.
New headaches
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.[50] 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 person, a temporal artery biopsy to look for temporal arteritis should be performed and immediate treatment should be started.[citation needed]
Neuroimaging
Old headaches
The US Headache Consortium has guidelines for neuroimaging of non-acute headaches.[51] 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.[52] If the person has neurological findings, such as weakness, on exam, neuroimaging may be considered.[citation needed]
New headaches
All people who present with
The American College of Radiology recommends the following imaging tests for different specific situations:[53]
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 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 |
Lumbar puncture
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.[11]
Classification
Headaches are most thoroughly classified by the
Other classification systems exist. One of the first published attempts was in 1951.[57] The US National Institutes of Health developed a classification system in 1962.[58]
ICHD-2
The
The ICHD-2 classification defines
Secondary headaches are classified based on their cause and not on their
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 exposure to some substances.
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.[citation needed]
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.[54]
NIH
The NIH classification consists of brief definitions of a limited number of headaches.[63]
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 causes. According to this classification, primary headaches can only be vascular,
Management
Primary headache syndromes have many different possible treatments. In those with chronic headaches the long term use of opioids appears to result in greater harm than benefit.[65]
Migraines
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.[11][67] Possible therapies include beta blockers, antidepressants, anticonvulsants and NSAIDs.[67] 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.[citation needed]
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
Sphenopalatine ganglion block (SPG block, also known nasal ganglion block or pterygopalatine ganglion blocks) can abort and prevent migraines, tension headaches and cluster headaches. It was originally described by American ENT surgeon Greenfield Sluder in 1908. Both blocks and neurostimulation have been studied as treatment for headaches.[69]
Several complementary and alternative strategies can help with migraines. The American Academy of Neurology guidelines for migraine treatment in 2000 stated
Tension-type headaches
Cluster headaches
Abortive therapy for cluster headaches includes subcutaneous sumatriptan (injected under the skin) and triptan nasal sprays. High flow oxygen therapy also helps with relief.[11]
For people with extended periods of 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.[11]
Secondary headaches
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 or brain radiation.
Neuromodulation
Peripheral neuromodulation has tentative benefits in primary headaches including cluster headaches and chronic migraine.[78] How it may work is still being looked into.[78]
Epidemiology
Literature reviews find that approximately 64–77% of adults have had a headache at some point in their lives.[79][80] During each year, on average, 46–53% of people have headaches.[79][80] However, the prevalence of headache varies widely depending on how the survey was conducted, with studies finding lifetime prevalence of as low as 8% to as high as 96%.[79][80][81] Most of these headaches are not dangerous. Only approximately 1–5% of people who seek emergency treatment for headaches have a serious underlying cause.[82]
More than 90% of headaches are primary headaches.[83] Most of these primary headaches are tension headaches.[80] 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.[80]
Approximately 12–18% of people in the world have migraines.[80] More women than men experience migraines. In Europe and North America, 5–9% of men experience migraines, while 12–25% of women experience migraines.[79]
Cluster headaches are relatively uncommon. They affect only 1–3 per thousand people in the world. Cluster headaches affect approximately three times as many men as women.[80]
History
The first recorded classification system was published by
Children
In general, children experience the same types of headaches as adults do, but their symptoms may be slightly different. The diagnostic approach to headaches in children is similar to that of adults. However, young children may not be able to verbalize pain well.[84] If a young child is fussy, they may have a headache.[85]
Approximately 1% of emergency department visits for children are for headache.
Just as in adults, most headaches are benign, but when head pain is accompanied with other symptoms such as
When children complain of headaches, many parents are concerned about a
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.[91] Treatments for children are similar to those for adults, however certain medications such as narcotics should not be given to children.[85]
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.[92] 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.[93]
See also
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[T]he prevalence [of headache within the last year] was on average 46% based on 35 different studies from all over the world, but the variation was immense, between 1% and 87%. The lifetime prevalence was much as expected – 64%, varying between 8% and 96% in 14 studies. For current chronic headache, the average of 10 studies was 3.4%, varying between 1.7% and 7.3%.
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Calculating the mean of all the studies comprising more than 205,000 adult participants, current headache [i.e. headache within the last year] occurred in 53% of adults (61% among women and 45% among men).... The total lifetime prevalence of headache among adults was as expected higher than that of current headache (77%).
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External links
- Headache at Curlie