Although painful and annoying, the vast majority of headaches do not indicate a serious disorder. Tension headache and migraine headaches account for 90% of all headaches.

The different types of headaches are usually caused by muscle contraction (tension headaches), vascular problems (migraine headache or cluster headache), or a combination of these two causes.

A headache that signals a potentially serious problem is one that:

• Involves sudden, violent pain
  • This type of headache could signal an aneurysm
• Gets worse over time and includes other symptoms such as nausea and vomiting, speech changes, visual changes, personality changes, etc.
• Headache that awakens one from sleep
  • Although rare, this type of headache could be caused by a brain tumor
• Includes nausea, vomiting, fever, and a stiff neck
  • This type of headache could be a sign of meningitis

Tension headache is a common headache pattern that may or may not be associated with psychosocial stressors. Tension headaches are characterized by:

• Pain usually felt in the back of the head and neck, and usually not one-sided.
• Pain that lasts for weeks or months with only brief periods of relief, although it may fluctuate in severity.
• Attacks that begin at any time of the day.
• Pain that is often described as a "tight band," pressing, but rarely throbbing, and never accompanied by fever.

Migraine headaches, which are often preceded by fatigue, depression, and visual disturbance (light flash, loss of peripheral vision, etc.), are characterized by:

• Pain that is characteristically only on one side at a time, but may involve the entire head.
• Pain that is throbbing in nature and usually develops in the morning and gradually becomes worse after an hour or so.
• Attacks that may occur every few days or weeks, or not for months. Migraines often continue for hours, but rarely last longer than a day or two.
• Pain that may be aggravated bystress, alcohol, or certain foods (such as chocolate), and are frequently accompanied by nausea and vomiting and relieved by sleep.
• Having a family history of migraine headaches.

Cluster headaches are a variation of and less common than migraine headaches. They occur mostly in men, while typical migraines are more common in women. Cluster headaches are characterized by pain that:

• Is often situated behind an eye and usually the same eye.
• Comes on very suddenly and without warning.
• Peaks within 5 to 10 minutes and disappears in less than an hour.
• Is often triggered by alcohol.
• Will awaken a person from sleep and occur several times a day for weeks and then stop.

Inflamed sinuses (acute sinusitis or chronic sinusitis) are characterized by:

• Pain that usually begins during or after a bad cold, particularly if there is postnasal drip.
• Pain that it is localized to one specific area of the face or head.
• Pain that is worse in the morning, before the mucus has had an opportunity to drain.
• Pain that it is made worse by coughing, sneezing, or sudden movements of the head.
• Pain that it is aggravated by alcohol, sudden temperature changes, and during cold seasons, going from a warm room out into the cold.
• A history of hay fever and allergies.

Temporal arteritis occurs mostly in people over age 50, and is characterized by:

• Pain that is aggravated by chewing
• Impaired vision
• Aches and pains all over the body
• The presence of a fever
• Weight loss
• Elevated blood ESR (estimated sedimentation rate)
• May progress to loss of vision

Other common causes of headaches include:

• Benign headache
• Common cold
• Fever
• Hangover
• Alcohol withdrawal
• Head injury
• Neck pain from strain or arthritis
• Head or neck infection NOT involving the brain (dental disease, ear infection, mastoiditis, pharyngitis, or sinusitis)
• Influenza
• Medications such as indomethacin, nitrates, and vasodilators
• Premenstrual syndrome (PMS)
• Stress
• Tooth abscess
• Withdrawal from caffeine, ergotamine, sympathomimetic drugs, or other medication
• Withdrawal from street drugs

Rare causes include:

• Cerebral aneurysm
• Brain tumor
• Stroke
• TIA
• Meningitis
• Encephalitis

Headaches may be relieved by resting with the eyes closed and head supported, or by relaxation techniques such as meditation. A massage or heat applied to the back of the upper neck can be effective in relieving tension headaches.

Over-the-counter pain medications are often effective headache relievers. For tension headaches, acetaminophen (Tylenol), aspirin, or ibuprofen (Advil or Motrin) are often effective.

Migraine headaches will often respond to aspirin or naproxen (Aleve). Studies have also shown Migraine Strength Excedrin to be quite effective.

Avoid giving aspirin or other salicylates to children because of the risk of Reye's syndrome and other disorders.

Prescription medications used for migraine headaches include mixtures of ergotamine and caffeine (Cafergot), Midrin, sumatriptan, and others. Sometimes medications for nausea and vomiting are helpful.

Medications may be given prophylactically to prevent headaches before they occur. Examples of these include nortriptyline, atenolol, and verapamil.

If you are using pain medications more than 2 days a week, you may be suffering from rebound headaches. Rebound headaches are caused by a cycle of using pain medications for short-term relief, which is then followed by the headache pain returning for increasingly longer periods of time despite taking more pain medications.

All types of pain pills (including over-the-counter pain pills such as acetaminophen, aspirin, ibuprofen, and naproxen), muscle relaxants, some decongestants, and caffeine can cause this pattern. If you think this may be a problem for you, talk to your health care provider.

To treat rebound headaches, stop taking all pain medications and other possible triggers for several weeks. Ask your health care provider what treatments can be used during the withdrawal period.

The following symptoms are serious -- see your health care provider promptly:

• The headache comes on suddenly and is explosive or violent.
• The headache gets worse over time or is associated with visual difficulties, slurring of speech, problems in moving arms or legs, or similar problems.
• The headache is associated with fever and a very stiff neck.
• The headache is associated with head injury.
• The headache is the worst you have ever had and comes on suddenly.

For the following, see your health care provider soon, but not as an emergency:

• The headache has persisted more than a few days.
• The headaches are worse in the morning, and no other symptoms are present.
• You have headaches frequently, and there is no known cause.

A history will be obtained and an examination of head, eyes, ears, nose, throat, neck, and nervous system will be performed.

The diagnosis is usually based on the history given by the patient. A "headache diary" may be helpful for recording information about headaches over a period of time. Medical history questions documenting headache in detail may include:

• Location
  • Is the headache located in the forehead or around the eyes (frontal or periorbital)?
  • Is the headache located in the back of the head (occipital)?
  • Is the headache located near the temples (temporal)?
  • Is the headache behind the eyeball (retrobulbar)?
  • Is the headache all over (generalized)?
  • Is the headache on one side only (unilateral)?
  • Is the headache always on the same side?
• Quality/type
  • Is this the worst headache in your experience?
  • Is this a new type of headache for you?
  • Would you describe the headache as pulsating (throbbing)?
  • Is it severe?
  • Is it moderately severe?
  • Is there a pressure or band-like sensation?
• Time pattern
  • Does the headache occur upon awakening in the morning?
  • Did the headaches begin with this episode of illness?
  • How long have you had headaches?
  • How long does each headache last?
  • Does the headache awaken you from sleep?
  • Did other symptoms begin shortly after the headaches began?
  • Did the headaches begin suddenly?
  • Do headaches occur repeatedly (recurrent)?
    • Do they occur multiple times daily?
    • Do they occur over a period of weeks?
  • Are the headaches worse during the day and better at night?
  • Does the headache reach maximum intensity over 1 to 2 hours?
  • Did they develop rapidly?
  • At what age did headaches begin?
• Aggravating factors
  • Are the headaches worse when lying down or in a reclining position?
  • Are the headaches worse when standing up?
  • Are the headaches worse when coughing, sneezing, straining, lifting (Valsalva maneuver)?
  • Are headaches triggered by reminders of a traumatic event?
  • Do they occur at a specific time related to your menstrual period (women)?
• Relieving factors
  • What home treatment have you tried?
  • How effective was it?
  • Is the headache relieved by medication that contains ergotamine (such as Cafergot and Midrin) or "triptans" (such as sumatriptan)?
• Associated complaints
  • Does nausea or vomiting accompany the headache?
  • Is the headache preceded by a pop/snap in the skull?
  • Do neurological symptoms (weakness, loss of speech, etc.) occur when you have a headache?
  • Is the headache preceded by temporary loss of half of the visual field or other visual problems?
  • Does the headache cause the eye to tear on the same side as where the headache is?
  • Is there nasal discharge or stuffiness on the same side?
  • What other symptoms are present?

Diagnostic tests that may be performed include:

• Head CT scan
• Head MRI
• Sinuses X-rays
• Temporal artery biopsy
• Lumbar puncture

Intervention: