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Headache: Definition, Types, and Treatment
What is a Headache?
A headache is pain or discomfort in the head, scalp, or neck region. It is one of the most common medical complaints worldwide — affecting virtually everyone at some point in life. Headache can be the primary disorder itself, or it can be a symptom of another underlying condition.
The International Classification of Headache Disorders (ICHD-3) divides headaches into:
- Primary headaches — the pain IS the condition (no underlying structural cause)
- Secondary headaches — pain caused by an underlying disease or structural problem
Headaches occurring < 15 days/month are called episodic; those occurring ≥ 15 days/month are chronic.
⚠️ RED FLAGS (Seek Emergency Care Immediately)
Per Goldman-Cecil Medicine, seek immediate evaluation if you have:
- "Worst headache of my life" (thunderclap headache — may indicate subarachnoid hemorrhage)
- Sudden new onset headache reaching peak within 1 minute
- Headache awakening from sleep
- New headache in older adults without prior history
- Headache with fever, stiff neck, rash (meningitis)
- Headache with focal neurological deficits
- Headache in a patient with HIV, cancer, or pregnancy
- Headache much worse when lying down or with Valsalva maneuver
PRIMARY HEADACHE TYPES
1. 🔴 Migraine
Epidemiology: Affects 15–20% of women and 4–7% of men; ~1 billion people worldwide. Peak prevalence between ages 25–55.
Pathophysiology: Caused by cortical spreading depression (brief blood flow reduction followed by hyperemia), triggering stimulation of trigeminal afferents in the dura. Serotonin dysregulation plays a key role.
Clinical Features:
| Feature | Details |
|---|---|
| Location | Usually unilateral (can be bilateral) |
| Character | Throbbing/pulsating, moderate to severe |
| Duration | 2–72 hours per episode |
| Associated | Nausea, vomiting, photophobia, phonophobia, osmophobia |
| Aura | Visual (most common — zigzag lines, blind spots), sensory, aphasic, or vertiginous |
| Worsened by | Physical activity |
| Behavior | Patient prefers to rest in a dark, quiet room |
Phases:
- Prodrome (hours to days before): fatigue, mood changes, food cravings
- Aura (if present): visual/sensory disturbance lasting 20–60 min
- Headache phase: the actual pain (2–72 hrs)
- Postdrome: fatigue, cognitive dulling
Triggers: Stress, hormonal changes (menstruation), alcohol, certain foods (chocolate, aged cheese), sleep disruption, bright light, strong odors.
2. 🟡 Tension-Type Headache (TTH)
Most common headache type — affects 60–80% of the population at some point.
Clinical Features:
| Feature | Details |
|---|---|
| Location | Bilateral, "band around the head" |
| Character | Dull, pressing, tightening (non-pulsating) |
| Severity | Mild to moderate |
| Duration | 30 minutes to 7 days |
| Associated | Mild light/noise sensitivity (but NOT both together); NO nausea/vomiting |
| Behavior | Not worsened by physical activity |
Pathophysiology: Myofascial tenderness (especially in chronic form); genetic factors are uncertain. Less well understood than migraine.
3. 🟠 Cluster Headache
Relatively uncommon (56–401 per 100,000), but severely debilitating. Male predominance (3:1 to 7:1); onset usually ages 20–30.
Clinical Features:
| Feature | Details |
|---|---|
| Location | Unilateral, behind/around one eye, temple, forehead |
| Character | Excruciating, sharp, boring, stabbing |
| Duration | 15 minutes – 2 hours per attack |
| Frequency | 1–8 attacks/day, often nocturnal |
| Autonomic features | Ipsilateral lacrimation, conjunctival injection, nasal congestion, rhinorrhea, ptosis, miosis, facial flushing, eyelid edema |
| Behavior | Patient paces, cannot sit still (opposite of migraine) |
| Triggers | Alcohol, histamine, nitroglycerin |
| Pattern | Episodic (clusters lasting weeks–months, then remission) or chronic (no remission) |
Pathophysiology: Inferior posterior hypothalamic activation on PET/fMRI; trigeminovascular complex and cranial autonomic system are activated.
4. 🟣 Medication Overuse Headache (MOH) / Rebound Headache
Affects 1–1.5% of the general population; accounts for 50–80% of patients at specialist headache clinics. Women are affected 3× more than men.
- Caused by frequent use (>10–15 days/month) of analgesics, triptans, or opioids
- Presents as chronic daily headache
- Treatment: gradual withdrawal of the overused medication
5. Other Primary Headache Types
| Type | Key Features |
|---|---|
| Hemicrania continua | Continuous unilateral pain, responds to indomethacin |
| Paroxysmal hemicrania | Short attacks (5–30 min), females > males, responds to indomethacin |
| SUNCT (Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing) | Very brief (seconds to 2 min), frequent attacks; male predominance |
| Thunderclap headache | Sudden onset, reaches peak within 1 minute; must rule out SAH |
| Exertional/cough headache | Triggered by physical effort or Valsalva; can be primary or signal serious disease |
| New Daily Persistent Headache (NDPH) | Sudden onset daily headache, persistent; often post-viral (including post-COVID) |
| Chronic Daily Headache | Any headache ≥15 days/month; includes chronic migraine, chronic TTH |
SECONDARY HEADACHE TYPES
Caused by an underlying condition — treating the cause resolves the headache.
| Cause | Example |
|---|---|
| Vascular | Subarachnoid hemorrhage, stroke, cerebral venous thrombosis, arterial dissection |
| Increased ICP | Brain tumor, hydrocephalus, idiopathic intracranial hypertension |
| Decreased ICP | Post-lumbar puncture headache, CSF leak (intracranial hypotension) |
| Infection | Meningitis, encephalitis |
| Sinus disease | Sinusitis |
| Medication-induced | Nitrates, hormonal contraceptives, overuse of analgesics |
| Systemic | Hypertension, anemia, hypothyroidism |
| Trauma | Post-traumatic headache (onset within 7 days of injury) |
| Pregnancy-related | Preeclampsia, idiopathic intracranial hypertension |
Idiopathic intracranial hypertension (IIH): Seen in obese women of childbearing age; presents with daily headache, pulsatile tinnitus, and visual obscurations. MRI shows characteristic findings. Treated with acetazolamide and weight loss.
TREATMENT
Migraine — Acute (Abortive) Treatment
Mild attacks:
- Acetaminophen 650–1000 mg
- NSAIDs: Ibuprofen 400–600 mg, Aspirin 250–1000 mg, Naproxen 500–825 mg, Diclofenac 50 mg
Moderate–severe attacks (migraine-specific therapy):
| Drug Class | Examples | Notes |
|---|---|---|
| Triptans (5-HT1B/1D agonists) | Sumatriptan, Rizatriptan, Zolmitriptan, Naratriptan, Almotriptan, Frovatriptan, Eletriptan | First-line for moderate–severe migraine; avoid in CAD, uncontrolled hypertension, hemiplegic migraine |
| Ergots | Ergotamine tartrate, Dihydroergotamine (DHE) | Significant vasoconstrictors; contraindicated in angina, peripheral vascular disease |
| Ditans (5-HT1F agonists) | Lasmiditan | Useful when triptans contraindicated (no vasoconstriction) |
| CGRP antagonists (gepants) | Rimegepant, Ubrogepant | Acute treatment when triptans are contraindicated or not tolerated |
| Antiemetics | Metoclopramide, Prochlorperazine | Add-on for nausea; also enhance analgesic absorption |
Key principle: Prompt treatment (at headache onset) improves outcomes vs. late treatment.
Migraine — Preventive (Prophylactic) Treatment
Used when attacks are frequent (≥4/month), prolonged, or severely disabling.
| Drug Class | Examples |
|---|---|
| Beta-blockers | Propranolol, Metoprolol, Timolol |
| Tricyclic antidepressants | Amitriptyline, Nortriptyline |
| Antiepileptics | Valproate, Topiramate |
| CGRP monoclonal antibodies | Erenumab, Galcanezumab, Fremanezumab, Eptinezumab (monthly or quarterly injections) — newer targeted therapy |
| Gepants (preventive) | Atogepant, Rimegepant |
| Botulinum toxin A | Onabotulinumtoxin A (for chronic migraine ≥15 days/month) |
| Calcium channel blockers | Verapamil (especially for cluster headache prevention) |
Tension-Type Headache Treatment
Acute:
- NSAIDs (preferred): Ibuprofen, Aspirin, Naproxen
- Acetaminophen: effective for mild cases
Prevention (chronic TTH):
- Tricyclic antidepressants (amitriptyline) — more efficacious than SSRIs
- Muscle relaxants
- Physical therapy, massage
- Botulinum toxin injection (localized)
- Acupuncture
- Cognitive behavioral therapy (CBT)
Cluster Headache Treatment
Acute:
- 100% oxygen inhalation — highly effective, rapid relief
- Triptans (sumatriptan subcutaneous or intranasal zolmitriptan) — first-line abortive
Preventive:
- Verapamil — most commonly used preventive
- Lithium carbonate — for chronic cluster
- Short-course corticosteroids — to break a cluster episode
- Melatonin — helpful in some patients
Non-Pharmacological (General) Approaches
Applicable across multiple headache types:
- Trigger avoidance: identify and avoid personal triggers (alcohol, certain foods, sleep deprivation, stress)
- Regular sleep schedule
- Hydration and regular meals
- Stress management: CBT, biofeedback, relaxation techniques
- Exercise: regular moderate aerobic activity
- Acupuncture: evidence supports use in chronic migraine and TTH
- Moist heat/ice packs
- Adequate rest in a dark, quiet environment during attacks (migraine)
Summary Comparison Table
| Feature | Migraine | Tension-Type | Cluster |
|---|---|---|---|
| Sex | Female > Male | Equal | Male >> Female |
| Location | Usually unilateral | Bilateral (band) | Unilateral (periorbital) |
| Character | Pulsating, throbbing | Dull, pressing, tightening | Excruciating, stabbing/boring |
| Severity | Moderate–severe | Mild–moderate | Very severe |
| Duration | 2–72 hours | 30 min–7 days | 15–90 min (1–8×/day) |
| Nausea/vomiting | Yes | No | Rarely |
| Photophobia/phonophobia | Both | At most one | Mild (unilateral) |
| Autonomic features | Subtle | None | Prominent ipsilateral |
| Aura | In ~25% | No | No |
| Activity | Worsens pain | No effect | Patient paces |
| Behavior | Rest in dark/quiet | Functional | Restless, agitated |
| Acute Rx | Triptans, NSAIDs | NSAIDs, acetaminophen | O₂ inhalation, triptans |
| Preventive Rx | Beta-blockers, CGRP mAbs, valproate | Amitriptyline, CBT | Verapamil, lithium |
Sources:
- Goldman-Cecil Medicine International Edition, Chapter 367
- Lippincott Illustrated Reviews: Pharmacology, Chapter 39
- Bradley and Daroff's Neurology in Clinical Practice
- PMID 39293828 — 2024 BMJ network meta-analysis on acute migraine drug interventions
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