Headaches - When To Be Concerned

Headaches affect nearly forty percent of people in the US and are among the most common medical complaints in my office. Migraine headache alone causes the loss of 150 million workdays and over 300,000 lost school days every year. If you suffer from headaches the most important questions you should be asking are a) what type of headache do I have? b) are they dangerous? c) are they treatable and preventable? My goal for this article is to provide you with guidance to the answers for each of these three questions.

Types of Headaches

The International Headache Society has established criteria for the diagnoses of different types of headaches. Ninety percent of all the headaches fit into one of the following categories: migraine-type, tension-related or cluster headaches. Between 40 % and 80% of al headaches seen in the office are of the migraine type.

Headache types can be divided into six basic causes:

1.Vascular headaches (migraine and cluster types)

2.Tension-type headaches

3.Headache due to vascular abnormalities (i.e.: brain aneurism)

4.Psychiatric headaches (psychogenic)

5.Headaches caused by a systemic disorder such as hypertension, fever or sinusitis

6.Other neurologic headaches such as those after injury, due to neck disorders, brain tumors, etc.

In order to understand the cause of a particular headache a physician must perform a thorough history and physical examination. Important questions I ask include:

-Age at which the headache began

-Whether or not a pre-headache sensation (prodrome) is appreciated

-The frequency, intensity and duration of the headaches

-The type and location of headache pain

-Any family history of migraine headaches

-Triggers and relieving factors

-The headache's relationship to alcohol consumption

-Any changes in vision

-Any history of head trauma

-Life stressors or environmental changes

-And others

Dangerous Headaches-Signs and Symptoms

-A sudden onset of headache or a severe persistent headache may be caused by bleeding in the brain, infection or other life-threatening condition...especially if the pain has never occurred in the past.

-If headaches worsen over time, or are associated with other symptoms (such as nausea) this could suggest a serious condition such as compressing the brain by fluid or tumor.

-Any change in the ability to move or feel requires an emergency medical evaluation

-Fever associated with headache is of particular concern, as meningitis needs to be considered

-Any change in a person's ability to think or act must be immediately evaluated by a physician

-Rapid onset of headache with strenuous exercise or after injury could suggest damage to an artery in the neck or head

-Headache that spreads to the lower neck suggests infection or bleeding around the brain

-New headaches in anyone who suffers from cancer must be evaluated quickly

-Headache and associated Lyme disease needs urgent medical evaluation

-Headache during pregnancy or soon after delivery suggests a serious cause for the pain

Diagnosing the Cause of a Headache

-Chronic nasal stuffiness or respiratory infections are associated with sinusitis

-Visual disturbances often mean migraine headache, headache caused by acute glaucoma, or even a brain tumor

-Headache made worse by standing may be due to a leak of spinal fluid

-Nausea, vomiting or a headache that worsens when bending suggests a brain tumor as the cause

-Fatigue, 'aches and pains' and night sweats in older headache sufferers suggests a disease called temporal arteritis

-A hormonal condition that raises blood pressure intermittently and is associated with headache is referred to as pheochromocytoma

Tests Utilized to Assist in the Diagnosis of Headaches

The American Academy of Neurology, American Academy of Family Physicians, American College of Physicians, American Society of Internal Medicine and four other groups formed a consortium and issued practice guidelines in 2000 that suggested brain imaging (brain MRI of CT scans) for patients with:

1.Headache and an unexplained abnormal finding on neurologic physical examination

2.Headache made worse with certain breathing maneuvers

3.Headaches that awaken people from sleep

4.New headaches in people over age 40 or progressively worsening headaches

5.Onset of headache with exertion, cough or sexual activity


Treatment choices depend on the headache's cause. Tension headaches are often successfully treated with analgesics (NSAIDS, aspirin, Tylenol). Muscle relaxers may be considered in resistant cases. Migraine headaches may be prevented with the use of medications called Triptans. Other drugs (ergots, analgesics and several others) play important roles in treating resistant migraine headaches. Cluster headache is treated with the addition of oxygen, ergots, calcium channel blockers or other medications.

If you are suffering from headache it is important to see your physician. Only after a thorough history and physical examination can the cause of your headache be determined and the proper choice of treatment started. If you experience any of the above 'Dangerous Signs and Symptoms', or if your headache is the 'worse headache you have ever had' see your physician or go to an emergency room immediately. Headaches are treatable. In my opinion no one should suffer from incapacitating or chronic headaches. Much can be done if the cause of a headache is determined and proper treatment is prescribed.

2/24/2015 8:00:00 AM
Stuart Hochron, MD
Practices Internal Medicine and Pulmonary Medicine in Woodbridge, New Jersey and Jersey City, New Jersey
View Full Profile Website: http://stuarthochronmd.com/

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