Headache

A guide to headache causes and treatments

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What are the different types of headache?

One of the best ways to look at headaches is to divide them into groups depending on how the pain starts.

Acute single headache

Only a minority of people seek medical advice after their first headache, although this can, occasionally, prove to be their first attack of migraine. There are, however, a number of other causes of this type of headache and it could be a pointer to a more serious problem.

Although headache is very common following a head injury, generally fading over weeks or months, it can sometimes be the first warning of the presence of a blood clot within or just outside the brain, which will need to be looked at more closely.

An acute single headache could also be a pointer to a subarachnoid haemorrhage or meningitis. Subarachnoid haemorrhage, which is usually caused by a ruptured aneurysm on a large blood vessel at the base of the brain or by an arteriovenous malformation, is discussed in detail in another Brain and Spine booklet, as is meningitis (see previous links above). In general terms, the pain of subarachnoid haemorrhage starts very suddenly and may be linked with temporary or even prolonged loss of consciousness, whereas the headache of meningitis starts more slowly in someone who is clearly unwell with a high temperature. Both of these can cause a stiff neck, though this does not happen in all cases. If either of these conditions is suspected, the affected person should be taken to hospital as a matter of urgency.

Headache is a common feature of any infectious disease which raises the body temperature, such as, ’flu or a chest infection. Sometimes an infection within the sinus cavities in the face develops with a common cold, and this is generally accompanied by headache. This infection usually causes tenderness in the bones above or below the eye on one or both sides and produces an opaque mucus which either drains backwards into the throat or forwards when the affected person blows their nose.

Recurring headache

The commonest single cause of disabling recurrent headache is migraine, which is discussed in detail later in this booklet. The headache usually lasts for between four and 48 hours. It is often throbbing, and frequently affects just one side of the head. A lot of people experience nausea and/or vomiting, and sensitivity to light and/or smells is common. A few complain of flashing lights, blindness, tingling in the face or fingertips or even
speech disturbances.

A less common type of recurrent headache is called cluster headache. The pain in this type of headache is shorter and much more severe. It is less often accompanied by any serious feelings of nausea and hardly ever by the visual disturbances linked with migraine, but many people find that the eye waters or becomes bloodshot, or that the eyelid droops on the same side as the headache.

More common than the cluster headache is the tension-type headache. Here the pain usually affects both sides of the head at once, it is not accompanied by nausea or any other symptoms affecting the nervous system, and it wears off after one to six hours. This type of headache is far more common than migraine in the general population, but most people realise it is harmless and treat it by taking ordinary painkillers, though a few are worried enough to seek medical advice.

Irritation of the trigeminal nerve, which tells the brain what the face is feeling, can sometimes produce neuralgia, most commonly affecting the lower jaw or teeth. The pain here is very short-lived, lasting only a moment or so, and has been compared to a red-hot knitting needle being thrust through the face. It can be triggered by chewing, eating, speaking, touching the face or even by the wind. This condition becomes rather more common in older people, probably because the arteries supplying the back of the brain where this nerve enters it become stretched and may touch the nerve (see also the Brain and Spine booklet Face Pain).

Some headache sufferers get migraine and tension type headache – it is important to recognise that both types of headache are occurring so they can be managed appropriately.

Triggered headache

Coughing, straining and exertion

Headache from any cause can be worsened by coughing or straining. Occasionally, however, people find that coughing will actually trigger a headache. This is sometimes due to a minor abnormality at the back of the skull, which can be corrected surgically. This may also be the case where a headache is triggered by lifting weights, whereas a headache occurring after running or other similar exercise is more likely to be caused by the increased speed at which the blood is circulating. This is usually considered harmless, but it can be prevented with drug treatment in some cases.

Headache can occasionally be triggered by sexual intercourse. It is often benign, or harmless, especially when it occurs repeatedly, but anyone experiencing pain for the first time under these circumstances should be assessed in hospital.

Food and drink

About one fifth of people with migraine seeking advice from a specialist clinic report that cheese and/or chocolate can trigger attacks. Most of these also have attacks when they have not eaten any cheese or chocolate as well, and very few can avoid experiencing headache completely by avoiding these foods. Some people affected by migraine are also sensitive to alcoholic drinks - some to red wine only, but others to all alcoholic drinks including white wine and clear spirits such as gin and vodka. It is not understood why these foods and drinks bring on attacks in some people, but there are migraine sufferers who have to abstain from some or all of these foods or drinks completely.

Dull headache increasing in severity over days and weeks

This pattern of headache is, perhaps, the one that causes most concern to patients, GPs and specialists. It must be stressed that benign headache can vary in intensity, and in the majority of cases, this type of headache is harmless. There are, nevertheless, a number of factors, which need to be looked at.

Overuse of medication

It has been known for many years that ergotamine, which is the active ingredient of many of the older, more potent migraine remedies, can cause headache if taken on a daily basis. More recently it has also become clear that codeine-containing painkillers (including medication containing dihydrocodeine or dextropropoxyphene, such as distalgesic) can also cause headache if taken to excess - the threshold being use of these medicines three to four days a week regularly.

It seems likely that in this case a headache is produced as a sort of withdrawal symptom once the beneficial effects of each dose have worn off. It is therefore very tempting to take a further dose, as this will provide short-term relief, but this will again produce a headache after some hours. People taking analgesics in these quantities are often seen in specialist clinics. If they stop the medication completely they will frequently have a very severe headache for a few days, but this will usually disappear within a week.

The contraceptive pill, and particularly the combined oestrogen/progesterone type which is taken for three weeks before stopping to have a period, often seems to worsen headache. It is believed that this type of headache is triggered by the falling levels of hormone, which explains why they are so common in the few days between stopping the pill and the start of the period. Sometimes these headaches follow a typically migraine-type pattern, but others affect both sides of the head, are not accompanied by vomiting, and are more like tension-type headaches.

Women who experience visual disturbances or abnormal sensations in their arms or legs immediately before their headaches are believed to be at a slightly greater risk of stroke if they carry on taking a combined contraceptive pill, particularly if they smoke, and it is widely believed that the pill should be stopped under these circumstances. The progesterone-only pill may be a good alternative as it is usually better tolerated in migraine sufferers and does not carry any additional risk of a stroke. However, in some cases women can only expect their headaches to settle down if they stop the pill completely.

Headache occasionally occurs as a side effect of other drug treatments. Common examples are nifedipine (Adalat), which is given for hypertension and glyceryl trinitrate, which is used under the tongue for anginal pain.

Temporal arteritis

This is an inflammatory disease of the arteries of the scalp which often causes people to develop extreme tenderness in their temples. Affected people are nearly always in their sixties or older, and complain of a steadily worsening headache which can be linked to aches and pains elsewhere in the body. This condition is very easy to treat and may produce visual problems if it is left untreated.

Idiopathic intracranial hypertension

This is a fairly rare cause of the gradually worsening type of headache, which may occur in young women, particularly those who are overweight. It has also been linked with the contraceptive pill and with some drug treatments. Doctors will usually use an ophthalmoscope to diagnose this condition, and this may be followed by a brain scan. What happens with this condition is not well understood, but the brain cells seem to swell, causing an increased pressure in the head. The diagnosis is confirmed if a high pressure of cerebrospinal fluid is found when a lumbar puncture is performed. The removal of some cerebrospinal fluid often helps the headache and may have to be repeated. There are a number of drugs which also seem to help.

Brain tumours

Brain tumours are rare in the population as a whole, and most come to light either because of epileptic fits or because part of the brain no longer works properly, causing, for example, weakness in an arm and/or leg, difficulty with vision to one side, speech problems or a personality change. For a person with a brain tumour to reach medical attention complaining only of headache and without any physical problems which might be more indicative of a tumour is extremely rare. Anyone with an unexplained and gradually worsening headache may benefit from a scan in order to reassure both themselves and the doctor, but in these cases the number of positive scans is extremely low.

Neck disease

Wear and tear on the joints of the neck can sometimes cause headache. The pain is usually worsened by moving the neck and can be relieved by anti-inflammatory painkillers.