Headache, called cephalea in medicine, is one of the most common medical complaints. It is difficult to find someone who has never had at least one attack of headache during his life.
Some headaches can be very intense and recurrent, leading the patient to think that there is something serious in his brain. Brain tumors and aneurysms are usually the biggest fears of those who are affected by a strong headache. It is not uncommon to receive terrified people, wanting the doctor to order a computed tomography scan of the skull, when, in fact, their pain is just a simple headache, easily diagnosed medically.
Headaches are usually divided into two groups:
- Primary headaches: these are those that are not caused by other diseases and whose causes are not yet well understood, such as migraine, for example.
- Secondary headaches: these are headaches caused by other diseases, such as tumour, aneurysm, sinusitis or spinal problems.
In this article, we will explain what the different types of headache are, what the typical symptoms of each are, and what the signs of severity are.
Types of headache
Although very common, people know very little about headaches and think they are all the same. In fact, there are several causes for headache.
The vast majority of headaches are benign and have a primary origin. 90% of cases are caused by one of the following three syndromes:
- Migraine (also called migraine).
- Tension headache.
- Cluster headache.
Among secondary headaches, there are severe causes, which account for less than 10% of cases, including:
- Brain tumors.
- Cerebral aneurysm.
- Hemorrhagic stroke.
- Temporal arteritis.
- Cerebral venous thrombosis.
There are also several other causes of secondary headache that, although painful, are not serious, life-threatening illnesses:
- Back problems.
- Abuse of painkillers.
- Herpes zoster.
- Trigeminal neuralgia.
- Post-trauma headache.
- Headache after spinal anesthesia or lumbar puncture.
Contrary to popular belief, vision problems such as myopia, hyperopia and astigmatism are not common causes of headache. They can even occur in some children, but they are not common causes of chronic headache in adults. There is also no direct association between chronic headache and liver problems.
As already mentioned, 90% of benign headaches fall into one of three major syndromes that will be explained below.
Contrary to what many people think, migraine is not the term used to describe any headache of strong intensity. Migraine is a specific type of headache that is usually accompanied by very intense headaches, but it has its own characteristics that are different from other forms of intense headache.
Migraine is characterized by a unilateral headache (70% of the cases), pulsatile and gradual onset, which usually worsens until it reaches great intensity. Migraine worsens with bright light and noise and may be accompanied by nausea, vomiting, or dizziness. The pain usually worsens with head movements and physical exertion. Hypersensitivity of the scalp is also common, which can cause the pain to worsen after brushing the hair. The crises can last from 4 to 72 hours.
Migraine is three times more common in women, occurs mainly between the ages of 20 and 40, and is usually hereditary. Obese people have a higher incidence. Migraine attacks can be so frequent that they occur more than four times a month.
20% of patients have aura, which is a symptom that is characteristic of migraine. Aura are neurological signs that precede the onset of pain. Typically, they are bright spots or bright rays in the eye and tingling in some region of the body that occur before the onset of headache. Sometimes, aura can present symptoms such as muscle weakness, partial vision loss and speech alterations, which scare patients a lot because they remind them of a stroke. The difference is that auras last on average only 20 minutes and usually disappear spontaneously after the onset of pain. Eventually, some symptoms of weakness may take longer to disappear.
There are several, rarer subtypes of migraine that can cause neurological symptoms that do not fit the definition of aura. These are signs and symptoms that are very similar to those of a stroke. Often only a neurologist can differentiate between them.
Cyclic vomiting syndrome is a rare condition that usually occurs in people with migraine and is characterized by repeated episodes (3-4 times per year) of vomiting attacks that can last from 3 to 6 days. Sometimes it is necessary to hospitalize patients to control the condition and to perform hydration and correction of hydroelectrolyte disturbances.
Migraine attacks can be triggered by stress, menstruation, hunger, exercise, birth control pills, perfume, smoke, soda, or foods that contain nitrite, aspartate, tyramine, or glutamate.
The diagnosis is clinical. MRI and CT scans are only performed when the condition is atypical and another diagnosis is suspected.
There is no cure for migraine, but the treatments available today are very effective.
Tension headache is the most common type of headache in the population. It affects more women than men and stress is usually the main trigger of the crisis.
The most modern classification subdivides tension headache into 3 classes:
- Infrequent tension headache: Less than 1 episode per month.
- Frequent tension headache: 1 to 14 episodes per month.
- Chronic tension headache: more than 15 episodes per month.
The characteristic of tension headache is that it is a mild to moderate headache, non-pulsating, without necessarily having other associated symptoms, unlike migraine. It can last from 30 minutes to 1 week. The most common complaint is a pinching pain throughout the head, radiating to the nape of the neck and, in some cases, up to the shoulders. It is also very common to find the muscles of the head, neck and shoulders tense and contracted.
Other symptoms that may be present include insomnia, fatigue, irritability, lack of appetite, difficulty concentrating.
The treatment is done with painkillers or anti-inflammatory drugs.
Because tension headache is a type of headache that can be very frequent, there is a group of patients who end up abusing painkillers to control the pain. This behavior can lead to another type of headache, which is medication-induced headache. Patients present with headache despite the use of analgesics, suggesting a condition of tolerance. There is a discussion whether the painkillers themselves can cause the headache. To avoid this complication, people with frequent headache attacks (regardless of the type) should be followed up by a neurologist.
Cluster headache is the least frequent and most severe of the three main types of primary headache. This type of headache is more common in men.
Cluster headache occurs in cycles of attacks (hence the term “cluster”), which may last for several weeks, interspersed with asymptomatic periods that may last for months to years. An attack usually lasts from 30 minutes to 3 hours and may occur up to 3 times a day.
The pain of cluster headache is typically unilateral and localized around one eye. Unlike migraine, which can vary from one side of the head to the other, cluster headache is usually always on the same side of the head. It is a pain of abrupt onset that quickly reaches its greatest intensity, often becoming excruciating.
Pain around the eye is usually associated with tearing and redness of the affected eye. A stuffy nose and runny nose may also occur.
There is no clear association of precipitating factors as in migraine and tension sickness. The consumption of alcohol and cigarettes may aggravate the crisis during the spells.
Interestingly, cluster headache is a headache that responds to the administration of oxygen in addition to common painkillers.
Signs of severity
As explained before, the vast majority of headache episodes are caused by benign pathologies. But, even people with a history of chronic headache are frightened by some crises. Everyone is afraid that a serious unidentified illness, such as a tumour or aneurysm, could be the cause of the headache .
It is impractical to perform CT scans in all people with headache. In general, the clinical history and a good physical examination are sufficient to define whether or not there is a need to perform an imaging test.
It is important to keep in mind the main characteristics of the primary headaches described above so as not to confuse them with the serious causes of headache.
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Warning signs of a headache
- Sudden onset: persistent, abrupt onset headaches, which reach their peak intensity in a few seconds, may indicate ruptured aneurysms or venous thrombosis. It is important to remember that cluster headache can present these characteristics, however, it usually lasts few hours, has typical localization and signs such as tearing and red eyes. Migraine usually starts as a mild to moderate pain and worsens over a period of hours.
- Worst headache of life: when the patient reports that the current picture is by far the worst headache of his life, or a completely different headache from the ones he usually has, more attention should be paid to the picture. Hemorrhages and infections can be the cause. These complaints in cancer, AIDS and immunosuppressed patients are particularly worrying.
- Concomitant infections: patients who have sinusitis, otitis, skin infections on the face have a higher risk of developing brain abscesses and meningitis . Infections after piercing implantation can be the entrance door.
- Fever: the presence of intense headache associated with fever without a defined cause, especially if there is neck stiffness, indicates meningitis. It is important to remember that fever by itself can cause headache. Do not confuse a flu with something more serious.
- Medications: some patients use medications such as corticosteroids, which facilitate infections, and anticoagulants, which facilitate bleeding.
- Alteration of the state of consciousness: obviously, patients who enter coma, present convulsive crises, sudden disorientation or neurological deficits should immediately seek emergency service.
- Trauma: headaches that occur after trauma should be evaluated more carefully, especially in the elderly, because of the risk of intracranial hemorrhages. Some people develop chronic headaches after a trauma to the skull.
- Family history: patients with first-degree relatives who have suffered ruptured aneurysms should also be evaluated more carefully.
Other signs should also draw attention, such as a headache that wakes the patient, a headache whose characteristics do not fit any of the primary causes, worsening of pain on effort (remember that migraine can have this characteristic), onset of headache after the age of 50, or visual changes that may suggest glaucoma.
There is no defined protocol on when to request or not a CT scan. Some conditions are obvious, such as neurological alterations, and others are more questionable. It depends on the doctor’s common sense and the patient’s clinical picture.