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Patient education: Headache causes and diagnosis in adults (Beyond the Basics)

Patient education: Headache causes and diagnosis in adults (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Mar 24, 2023.

HEADACHE OVERVIEW — Headaches can be quite debilitating, although most headaches are not caused by life-threatening disorders. Most headaches fall into one of the following categories (table 1 and figure 1):

Tension-type headache

Migraine headache

Cluster headache

There is some overlap among the types of headaches, but some key symptoms help to tell them apart (figure 1). These three types represent the majority of "primary headache disorders." Primary headache disorders are headaches that are not caused by another medical condition. Any of these three primary types of headache may become frequent and even occur daily in some people. The presence of a daily headache may raise suspicion for worrisome causes of headache, especially if this is a new development. Depending on the person's history and exam, further testing may be needed.

The causes and diagnosis of non-migraine headaches are discussed here. Migraine headaches are discussed in greater detail separately. (See "Patient education: Migraines in adults (Beyond the Basics)".)

Information about headache treatments, as well as an overview of headache in children, is also available separately. (See "Patient education: Headache treatment in adults (Beyond the Basics)" and "Patient education: Headache in children (Beyond the Basics)".)

TENSION-TYPE HEADACHE — Symptoms of tension-type headaches include:

Pressure or tightness around both sides of the head or neck

Mild to moderate pain that is steady and does not throb

Pain is not worsened by activity

Pain can increase or decrease in severity over the course of the headache

There may be tenderness in the muscles of the head, neck, or shoulders

People with tension-type headaches often feel stress or tension before their headache. Unlike migraine, tension headaches occur without other symptoms such as nausea, vomiting, sensitivity to lights and sounds, or an aura.

MIGRAINE HEADACHES — Migraine headaches causes moderate to severe pain that is worsened by light, noise, and motion. Some people also experience nausea and vomiting. Migraine headaches typically last for a few hours but may last for as long as three days. When a person has a migraine, it usually is soothing to rest with the lights off in a quiet room. Females are affected more commonly than males and often have new onset of migraine during puberty or childbearing years. Some females note a change in their headaches around menopause.

Migraines are discussed in detail in a separate article. (See "Patient education: Migraines in adults (Beyond the Basics)".)

CLUSTER HEADACHE — Cluster headaches are severe, debilitating headaches that occur repeatedly in "clusters," often at certain times of the day for weeks to months at a time, followed by periods with no headache. Cluster headaches are relatively uncommon, affecting less than 1 percent of people. Males are affected more commonly than females, with a peak age of onset of 25 to 50 years. People who have cluster headaches usually become restless and agitated and often pace during the headache. The feeling of restlessness is a good way to tell the difference between cluster headache and migraine, as restlessness usually does not occur with migraine headaches.

Cluster headaches:

Begin quickly without any warning and reach a peak within a few minutes.

The headache is usually deep, excruciating, continuous, and explosive in quality, although occasionally it may be pulsatile and throbbing.

The attack may occur up to eight times per day but is usually short in duration (between 15 minutes and three hours).

The pain typically begins in or around the eye or temple; less commonly, it starts in the face, neck, ear, or side of the head.

The pain is always on one side.

Most people with cluster headache are restless and may pace or rock back and forth when an attack is in progress.

Cluster headaches are associated with eye redness and tear production on the side of the pain, a stuffy and runny nose, sweating, and pale skin.

Some people are light sensitive in the eye on the affected side.

Cluster headaches can begin at any age. People with cluster headaches are more likely to have family members who also have cluster headaches. Drinking alcohol can bring on a cluster headache and people who smoke are more likely to have more severe cluster headaches.

DIFFERENTIATING AMONG THE PRIMARY HEADACHE SYNDROMES — There is some overlap among the primary headache syndromes (figure 1), which can make it hard to tell the difference between the three. The symptoms that are present when the headache is most severe are often the most useful in differentiating the different types of headache. Some migraine headaches can cause tearing, eye redness, and nasal congestion, but those symptoms usually involve both sides of the head when they occur with a migraine. In contrast, those symptoms usually affect just one side with cluster headaches. In some cases of cluster headache, light and sound sensitivity may occur but usually only on one side. Some people with migraine will have a constant background tension-type headache in between their severe migraine headaches.

CHRONIC DAILY HEADACHE — Some people develop very frequent headaches, as frequent as every day in some cases. When a headache is present for more than 15 days per month for at least three months, it is described as a chronic daily headache.

Chronic daily headache is not a type of headache but a category that includes frequent headaches of various kinds. Most people with chronic daily headache have migraine or tension-type headache as the underlying type of headache. They often start out having an occasional migraine or tension-type headache, but the headaches became more frequent over months or years. Some people with frequent headache use headache medications too often, which can lead to "medication-overuse headaches." (See 'Medication-overuse headache' below.)

Medication-overuse headache — Medication-overuse headache may occur in people who have frequent migraine, cluster, or tension-type headaches, which leads them to overuse pain medications. A vicious cycle occurs in which frequent headaches cause the person to take medication frequently (often non-prescription medication), which then causes a rebound headache as the medication wears off, causing more medication use, and so on. Medication overuse headache can even occur if a person is taking daily analgesics to treat other areas of pain, as the body does not care why the person is taking the medication. This headache from frequent medication use is a result of the body's dependence on the medication.

Overuse of any number of pain medications can increase the risk of developing medication-overuse headaches. To avoid medication-overuse headaches, we recommend the following:

If possible, avoid medications that contain butalbital (sample brand name: Fioricet) and opioids completely.

Do not use triptans or aspirin/acetaminophen/caffeine combinations (sample brand name: Excedrin) more than nine days per month.

Do not use nonsteroidal antiinflammatory drugs (NSAIDs) more than 14 days per month.

More information about the different medications used to treat and prevent headaches is available separately. (See "Patient education: Headache treatment in adults (Beyond the Basics)".)

OTHER TYPES OF HEADACHE — There are a number of other causes of headache.

Post-trauma headaches — Headaches that occur within one to two days after a head injury are relatively common. Most people report a generalized dull, aching, constant discomfort that worsens intermittently. Other common symptoms include vertigo (sensation of spinning), lightheadedness, difficulty concentrating, problems with memory, becoming tired quickly, and irritability.

Post-trauma headaches may continue for up to a few months, although anyone with a headache that does not begin to improve within a week or two after a traumatic event should see a health care provider.

Sinus headache — Recurrent headaches related to sinus infections are uncommon. When they do occur, they typically occur along with thick yellow, green, or brown mucus from the nose. Many, if not most, people diagnosed with sinus headaches actually have migraine headaches. (See "Patient education: Migraines in adults (Beyond the Basics)".)

Sinus-related pain usually lasts for several days (unlike a typical migraine) and does not cause nausea, vomiting, or sensitivity to noise or light (as seen in migraine). The headache from a sinus infection improves as nasal discharge improves. (See "Patient education: Chronic rhinosinusitis (Beyond the Basics)".)

Headaches and arthritis — Pain from the upper cervical (neck) joints can also affect the head. When this happens, the headache usually starts in the neck or back of the head and spreads to the front of the head or temples. Typically, the headache is one sided, and pain is worsened with neck movements. In some cases, people will have reduced movement of their neck or pain when touching the neck. Usually this occurs later in life (after about age 50) as arthritis develops but can happen earlier if there is a history of whiplash injury. (See "Patient education: Neck pain (Beyond the Basics)" and "Patient education: Whiplash (The Basics)".)

Headaches and brain tumor — Headaches occur in approximately 50 percent of people who have brain tumors. However, headaches are very common and brain tumors are rarely found in people who are evaluated for headaches. Many people with brain tumors have chronic headaches that are worse with bending over or occur with nausea and vomiting, although these symptoms can also occur with headaches not related to a brain tumor.

HEADACHE DANGER SIGNS — The vast majority of headaches are not life threatening. However, headache can be a symptom of serious conditions affecting the brain, such as infection, inflammation, or bleeding within or around the brain. You should seek medical attention immediately if your headache:

Comes on suddenly, becomes severe within a few seconds or minutes, or that could be described as "the worst headache of your life."

Is severe and occurs with a fever or stiff neck.

Occurs with a seizure, personality changes, confusion, or passing out.

Begins quickly after strenuous exercise or minor injury.

Is new and occurs with weakness, numbness, or difficulty seeing. While migraine headaches can sometimes cause these symptoms, you should be evaluated urgently the first time these symptoms appear.

If you have persistent or frequent headaches, headaches that interfere with normal activities, or your headaches become more painful, you should see a health care provider during normal office hours.

HEADACHE DIAGNOSIS — Health care providers typically use a person's description of their headache, in combination with an examination, to determine the type of headache. Some people have more than one type of headache.

Most people do not need X-rays or other imaging tests. A computed tomography (CT) scan (or magnetic resonance imaging [MRI]) may be recommended in some circumstances, for example, if symptoms are unusual, if there are any danger signs (see 'Headache danger signs' above), or if there are any abnormalities seen during the examination. Other possible reasons for brain imaging include:

A sudden change in the pattern of headaches

Headaches that steadily worsen despite treatment

Signs or symptoms that suggest that another medical condition may be causing symptoms

HEADACHE TREATMENT — The treatment of headaches is discussed separately. (See "Patient education: Headache treatment in adults (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Headaches in adults (The Basics)
Patient education: Migraines in adults (The Basics)
Patient education: Headaches in children (The Basics)
Patient education: Head injury in adults (The Basics)
Patient education: Arteriovenous malformations in the brain (The Basics)
Patient education: Astrocytoma (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Migraines in adults (Beyond the Basics)
Patient education: Headache treatment in adults (Beyond the Basics)
Patient education: Headache in children (Beyond the Basics)
Patient education: Chronic rhinosinusitis (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute mild traumatic brain injury (concussion) in adults
Acute treatment of migraine in adults
Overview of thunderclap headache
Chronic migraine
Cluster headache: Treatment and prognosis
Cluster headache: Epidemiology, clinical features, and diagnosis
Estrogen-associated migraine headache, including menstrual migraine
Evaluation of headache in adults
Evaluation of the adult with nontraumatic headache in the emergency department
Headache during pregnancy and postpartum
Migraine-associated stroke: risk factors, diagnosis, and prevention
Hypnic headache
Medication overuse headache: Etiology, clinical features, and diagnosis
Migraine with brainstem aura
Chronic daily headache: Associated syndromes, evaluation, and management
Pathophysiology, clinical manifestations, and diagnosis of migraine in adults
Post dural puncture headache
Preventive treatment of episodic migraine in adults
Tension-type headache in adults: Acute treatment
Tension-type headache in adults: Etiology, clinical features, and diagnosis
Tension-type headache in adults: Preventive treatment

The following organizations also provide reliable health information.

National Library of Medicine

     (https://medlineplus.gov/headache.html, available in Spanish)

National Institute of Neurological Disorders and Stroke

     (https://www.ninds.nih.gov/Disorders/All-Disorders/Headache-Information-Page)

American Headache Society

     (https://americanheadachesociety.org)

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ACKNOWLEDGMENTS — The editorial staff at UpToDate would like to acknowledge Zahid H Bajwa, MD and R Joshua Wootton, MDiv, PhD, who contributed to earlier versions of this topic review.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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