Headaches in Adults

Primary Headaches

Among primary headaches, nearly 90% are categorized under migraine, tension headache, and cluster headaches. In terms of prevalence and actual clinical diagnosis, episodic tension-type headache (TTH) is the most frequent type suffered by many; most people who experience tension headache rarely seek medical attention, however.

On the other hand, among those who do seek medical attention, migraine is the most common diagnosis.

Cluster headache has the lowest prevalence, but often causes the most significant disability. As a result, majority of sufferers immediately seek medical attention for the condition.

What type of headache do you have?

Migraine is often characterized by recurring attacks that may occur only one side (unilateral) and described as either throbbing or pulsing. Sufferers also often experience nausea, vomiting, and/or extreme sensitivity to light and/or sound. This headache can be triggered by stress, menstruation, visual stimuli, weather changes, nitrates, fasting, wine, sleep disturbances, and aspartame, among others. The recurring attacks are more often than not disabling.

Tension headache is often a mild to moderate and non-throbbing pain that is felt on both sides (bilateral).

Cluster headache is often a severe, unilateral attack usually around the area of the eye or the temple, and also often accompanied by various other symptoms. These other symptoms are also felt on the same side as the headache, and include eye redness, tearing, drooping of the eyelid, runny nose, and/or nasal congestion. A cluster headache can reach full intensity in a few minutes, and usually lasts between 15 minutes and two-and-a-half hours.

Secondary Headaches

Secondary headaches occur as a direct result of another condition, such as fever, sinusitis, or high blood pressure. In a small percent of cases, the underlying condition is a neurologic disorder, such as posttraumatic headache, cervical spine disease, and other brain conditions.

What to Expect During Your Visit to the Doctor

In addition to a physical examination, your doctor will also conduct a thorough review of your history and will ask about the following in relation to your headache:

• Age at onset
• Presence/absence of aura, in the form of flashing lights, a gleam of light, blurred vision, or an odor; the occurrence of other symptoms that usually occur immediately before the headache
• Frequency, intensity, and duration of attack; time and mode of onset
• Number of headache days per month
• Quality, site, and radiation of pain
• Family history of migraine
• Precipitating and relieving factors; effect of certain activities on pain; effect of alcohol and certain foods on pain
• Exacerbation or relief with change in position
• Response to any previous treatment; effect of current medications; association with recent trauma
• Any recent change in vision; any recent changes in sleep, exercise, weight, or diet; change in work or lifestyle
• State of general health
• For women: change in method of birth control; effects of menstrual cycle and hormonal changes
• Possible association with environmental factors

The actual physical examination will involve the following:

• Obtain blood pressure and pulse
• Listen for a murmur in the neck, eyes, and head
• Palpate the head, neck, and shoulder regions
• Check temporal and neck arteries
• Examine the spine and neck muscles
• Neurologic examination, including coordination and sensory tests
• Gait examination involving balance tests

Migraine Diagnostic Questions

ID Migraine screen: A score of 2 out of 3 indicates the patient is positive for migraine.

• During the last three months, did you feel nauseated or sick to your stomach?
• Did light bother you a lot more than when you do not have headaches?
• Did your headaches limit your ability to work, study, or do what you needed to do for at least one day?

Brief headache screen:

• How often do you get severe headaches (ie, without treatment, is it difficult to function)?
• How often do you get other, milder headaches?
• How often do you take headache relievers or pain pills?
• Has there been any recent change in your headaches?

Headache Red Flags

Certain symptoms could suggest a serious underlying cause for your headache, such as a mass, an inborn vascular condition, or an infection, just to name a few. These symptoms often require brain imaging.

The mnemonic SNOOP is an effective reminder of headache red flags to watch out for:

• Systemic symptoms, illness, or condition, including fever, weight loss, pregnancy, or cancer
• Neurologic symptoms or abnormal signs, including confusion, impaired alertness or consciousness, or seizures
• Onset is new (particularly for those below 50 years of age) or sudden
• Other associated conditions or features, including head trauma, illicit drug use, toxic exposure; sleep is disturbed; cough, exertion, or sexual activity
• Previous headache history with headache progression or change in attack frequency, severity, or clinical features

Need for Emergency Evaluation

Seek emergency diagnosis and treatment if you experience these headache symptoms:

• Sudden onset “thunderclap” headache. This usually intensifies within a few seconds or less than one minute from the first onset of pain. This may indicate a subarachnoid hemorrhage.
• Acute or subacute neck pain or headache with Horner syndrome and/or other neurologic problems, such as abnormal reflexes or the inability to speak. This may indicate an ischemic stroke or transient ischemic attack.
• Headache with fever, altered mental status, and/or a rigid neck may indicate meningitis or encephalitis.
• Headache with disturbances in vision and vision, or with speech and hearing problems and neurologic symptoms that affect the left side of the face, right arm, or the tongue may indicate increased intracranial pressure (ICP).
• Headache with visual impairment, pain around the eyes, or paralysis of eye muscles may indicate glaucoma, infection, inflammation, or tumor.
• Headache and possible carbon monoxide exposure.

Other Secondary Headache Symptoms

• Impaired vision or seeing halos around light may indicate glaucoma.
• Visual field defects, or a loss of part of the usual field of vision, may indicate an optic lesion.
• Sudden, severe, unilateral vision loss may indicate damaged optic nerve. Headache behind the eyes may present in this condition.
• Blurring of vision when head is bent forward; headaches upon waking in the morning that improve when sitting up; double vision or loss of coordination and balance; chronic, daily, progressively worsening headaches and nausea may indicate increased intracranial pressure (pressure inside the skull).
• Headaches that improve when lying down or reclining and worsen with upright pressure may indicate intracranial hypotension, or negative pressure within the brain cavity.
• Headache and Nausea, vomiting, worsening headache with changes in body position, and/or a significant change in prior headache pattern may indicate a tumor.
• Intermittent headache with sweating, increased heart rate (tachycardia), and/or sustained episodic high blood pressure may indicate an adrenal gland tumor.
• Morning headaches may indicate sleep apnea, chronic obstructive pulmonary disease (COPD), and obesity hypoventilation syndrome (low oxygen and increased CO2 levels in obese individuals).

New or Recent Onset Headaches

The absence of similar headaches in the past, combined with the following high-risk factors, may indicate a serious disorder (e.g. brain lesion, hematoma, hydrocephalus, or a cerebral edema from a stroke) and warrant serious and immediate medical attention:

• Patients older than 50
• Patients with cancer
• Patients with Lyme disease
• Patients with a fever
• Patients with a compromised immune system
• Patients that also experience neurologic problems

Headaches In Older Patients

Older patients are at an increased risk for secondary headaches and some types of primary headaches, which may be associated with the following underlying conditions:

• Giant cell arteritis (GCA), the most common form of vasculitis in adults over 50 years of age and is characterized by the inflammation of the lining of the arteries.
• Trigeminal neuralgia, characterized by a jolt of excruciating pain upon even mild stimulation of the face, e.g. brushing teeth or putting on makeup.
• Chronic subdural hematoma, or brain bleed.
• Acute chickenpox and postherpetic neuralgia from shingles, characterized by burning pain even after the rashes and blisters have disappeared.
• Brain tumor.
• Alarm clock headache or hypnic headache, characterized by disturbed sleep.
• Primary cough headache

Headaches In Pregnant Woman

In addition to migraine or another primary headache, a headache during pregnancy may also indicate the following:

• Pre-eclampsia
• Postdural puncture headache, following an epidural procedure
• Cerebral venous thrombosis (CVT), or a blood clot in the brain

Headaches With Fever

Fever associated with headaches may indicate intracranial, systemic, or local infection, especially meningitis or encephalitis. However medical attention needs to be seen to confirm a serious condition is not present.

Headaches From Head Injury

Headaches are common in patients who have experienced mild head trauma. However medical attention needs to be seen to confirm a serious condition is not present.

Sinus Headache

Sinus-related pain or headache is often characterized by pressure around the sinuses and/or the eye area; it is also usually associated with nasal congestion, nasal discharge, headache and nausea, vomiting, and/or sensitivity to light and sound.

Chronic Headache

The term “chronic” refers to either the frequency of headaches or their duration; chronic headache encompasses both primary and secondary headaches.

Long-duration chronic headaches indicate a duration of four hours or more and a headache frequency of 15 or more days a month for longer than three months.

Short-duration chronic headaches indicate a duration of less than four hours and a frequency of several times a day.

Other Diagnostic Tools

• Imaging exam through computed tomography (CT) or magnetic resonance imaging (MRI)
• Lumbar puncture for cerebrospinal fluid (CSF) analysis

Treatment options for headache is best achieved through a combination of injections in conjunction with graded rehabilitative exercise and possibly medication. How to get rid of a headache depends on the individual cause. For example, in headache back of head location, posture and neck muscles are evaluated to reduce daily stress. Migraine relief requires removing triggers and focusing on prevention.

If your pain does not resolve after a brief period, contact us so that we may help diagnose the problem and treat the underlying cause. Do not let pain persist or else it may become chronic.