Dr. Vincent Fortanasce has been a member of the National Headache Association since 1981. He has family members who suffer from migraines. The Fortanasce – Purino Neurology Center gives community lectures on headache disorders and the latest treatments.

What is a Headache?

A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Several areas of the head and neck have these pain-sensitive structures, which are the cranium (the periosteum of the skull), muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes.

There are a number of different classification systems for headaches. The well-recognized is that of the International Headache Society. Treatment of a headache depends on the underlying etiology or cause, but commonly involves analgesics.

There are over 200 types of headache, and the causes range from harmless to life-threatening. The description of the headache, together with findings on neurological examination, determines the need for any further investigations and the most appropriate treatment.

Primary headaches

The most common types of headache are the “primary headache disorders”, such as tension-type headache and migraine. They have typical features; migraine, for example, tends to be pulsating in character, affecting one side of the head, associated with nausea, disabling in severity, and usually lasts between 3 hours and 3 days. Rarer primary headache disorders are trigeminal neuralgia (a shooting face pain), cluster headache (severe pains that occur together in bouts), and hemicrania continua (a continuous headache on one side of the head).[9]

Secondary headaches

Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication overuse headache may occur in those using excessive painkillers for headaches, paradoxically causing worsening headaches.

A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes; some of these may be life-threatening or cause long-term damage. A number of “red flag” symptoms therefore mean that a headache warrants further investigations, usually by a specialist. The red flag symptoms are a new or different headache in someone over 50 years old, headache that develops within minutes (thunderclap headache), inability to move a limb or abnormalities on neurological examination, mental confusion, being woken by headache, headache that worsens with changing posture, headache worsened by exertion or Valsalva maneuver (coughing, straining), visual loss or visual abnormalities, jaw claudication (jaw pain on chewing that resolves afterwards), neck stiffness, fever, and headaches in people with HIV, cancer or risk factors for thrombosis.

“Thunderclap headache” may be the only symptom of subarachnoid hemorrhage, a form of stroke in which blood accumulates around the brain, often from a ruptured brain aneurysm. Headache with fever may be caused by meningitis, particularly if there is meningism (inability to flex the neck forward due to stiffness), and confusion may be indicative of encephalitis (inflammation of the brain, usually due to particular viruses). Headache that is worsened by straining or a change in position may be caused by increased pressure in the skull; this is often worse in the morning and associated with vomiting. Raised intracranial pressure may be due to brain tumors, idiopathic intracranial hypertension (IIH, more common in younger overweight women) and occasionally cerebral venous sinus thrombosis. Headache together with weakness in part of the body may indicate a stroke (particularly intracranial hemorrhage or subdural hematoma) or brain tumor. Headache in older people, particularly when associated with visual symptoms or jaw claudication, may indicate giant cell arteritis (GCA), in which the blood vessel wall is inflamed and obstructs blood flow. Carbon monoxide poisoning may lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and blurred vision. Angle closure glaucoma (acute raised pressure in the eyeball) may lead to headache, particularly around the eye, as well as visual abnormalities, nausea, vomiting and a red eye with a dilated pupil.

Origins and Classifications of Headaches

The brain itself is not sensitive to pain, because it lacks pain receptors. However, several areas of the head and neck do have nociceptors, and can thus sense pain. These include the extracranial arteries, large veins, cranial and spinal nerves, head and neck muscles and the meninges.

Headache often results from traction to or irritation of the meninges and blood vessels. The nociceptors may also be stimulated by other factors than head trauma or tumors and cause headaches. Some of these include stress, dilated blood vessels and muscular tension. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts.

The NIH classification of headaches outlines five types of headache: vascular, myogenic (muscle tension), cervicogenic, traction, and inflammatory.

Vascular Headache

The most common type of vascular headache is migraine. Migraine headaches are usually characterized by severe pain on one or both sides of the head, an upset stomach, and, for some people, disturbed vision. It is more common in women. While vascular changes are evident during a migraine, the cause of the headache is neurological, not vascular. After migraine, the most common type of vascular headache is the “toxic” headache produced by fever.

Other kinds of vascular headaches include cluster headaches, which are very severe recurrent short lasting headaches, often located through or around either eye and often wake the sufferers up at the same time every night. Unlike migraines, these headaches are more common in men than in women.

Muscular or Myogenic Headaches

Muscular (or myogenic) headaches appear to involve the tightening or tensing of facial and neck muscles; they may radiate to the forehead. Tension headache is the most common form of myogenic headache.

Cervicogenic Headaches

Cervicogenic headaches originate from disorders of the neck, including the anatomical structures innervated by the cervical roots C1-C3. Cervical headache is often precipitated by neck movement and/or sustained awkward head positioning. It is often accompanied by restricted cervical range of motion, ipsilateral neck, shoulder, or arm pain of a rather vague non-radicular nature or, occasionally, arm pain of a radicular nature.

Traction/Inflammatory Headaches

Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection.

Specific Types of Headaches:

  • Tension headache
  • Migraine
  • Idiopathic intracranial hypertension (headache with visual symptoms due to raised intracranial pressure)
  • Ictal headache
  • Cluster headache
  • “Brain freeze” (also known as: ice cream headache)
  • Thunderclap headache
  • Vascular headache
  • Toxic headache
  • Coital cephalalgia (also known as: sex headache)
  • Hemicrania continua
  • Rebound headache (also called medication overuse headache, abbreviated MOH)
  • Red wine headache
  • Spinal headache” (or: post-dural puncture headaches) after lumbar puncture or related procedure that will lower the intracranial pressure
  • Withdrawal (caused by medication or other dependency creating substance removal/cessation)
  • Hangover (caused by heavy alcohol consumption)
  • New daily persistent headache

Headache Test

    1. Have your headaches worsened over the past year? Yes or No
    2. Does coughing, straining or lifting worsen the pain? Yes or No
    3. Have you noticed new symptoms or visual loss, weakness or numbness? Yes or No
    4. Are your headaches worse in the morning? Yes or No
    5. Is your headache “explosive”? Yes or No

If you answered yes to at least 3 of questions 1-5, it may mean your headache is very serious.

    1. Do you have a family history of migraines? Yes or No
    2. Do you get visual or other symptoms before your headache begins? Yes or No
    3. Are your headaches throbbing and/or begin on the side of your head? Yes or No

If you answered yes to any of questions 6-8, than it maybe a migraine.

    1. Do your headaches awaken you at night? Yes or No
    2. Are your headaches present 24/7? Yes or No
    3. Are your headaches a steady diffuse pain? Yes or No
    4. Do you have insomnia? Yes or No

If you answered yes to any of questions 9-12, then your headaches maybe stress related.

  1. Does your headache start in your neck and shoulders? Yes or No
  2. Does reading or using a computer worsen your headaches? Yes or No
  3. Does your neck “crack” when you turn it? Yes or No

If you answered yes to any of questions 13 – 15, than your headaches maybe related to a neck problem.