What is headache? Explain types and cure in details
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Headache: Definition, Types & Treatment
What Is a Headache?
Headache (cephalalgia) is pain or discomfort in the region of the cranial vault — encompassing aches arising from the scalp, meningeal arteries, dural sinuses, falx cerebri, and proximal segments of large pial arteries. Importantly, much of the brain parenchyma itself, ventricular ependyma, choroid plexus, and pial veins are not pain-sensitive.
Pain arises via the trigeminovascular system: the trigeminal nerve innervates intracranial vessels and dura mater, and signals are relayed through the trigeminocervical complex (caudal trigeminal nucleus + upper cervical spinal cord) to the thalamus and cortex. Autonomic symptoms (tearing, nasal congestion, ptosis) reflect cranial parasympathetic pathway activation — they are secondary, not causative.
"Migraine is a brain disorder and is best understood and managed as such." — Harrison's Principles of Internal Medicine, 22e
Classification: Primary vs. Secondary
The International Headache Society (IHS) ICHD-3 divides all headaches into two major groups:
| Category | Description | Prevalence |
|---|---|---|
| Primary | No underlying structural cause; headache IS the disease | ~90% of all headaches |
| Secondary | Caused by an identifiable underlying condition | ~10% |
Primary Headache Prevalence (Harrison's):
| Type | % of Primary Headaches |
|---|---|
| Tension-type | 69% |
| Migraine | 16% |
| Idiopathic stabbing | 2% |
| Exertional | 1% |
| Cluster | 0.1% |
Secondary Headache Causes:
| Cause | % |
|---|---|
| Systemic infection | 63% |
| Head injury | 4% |
| Vascular disorders | 1% |
| Subarachnoid hemorrhage | <1% |
| Brain tumor | 0.1% |
PRIMARY HEADACHES IN DETAIL
1. Tension-Type Headache (TTH)
The most common headache overall — affecting ~75% of people at some point.
Features:
- Location: Always bilateral, band-like or pressing sensation around the head
- Quality: Dull, steady, non-throbbing, non-pulsating
- Severity: Mild to moderate; does not incapacitate
- Duration: 30 minutes to several hours (episodic) or continuous (chronic)
- No nausea, vomiting, photophobia, or phonophobia (distinguishes it from migraine)
- Chronic TTH: occurs >15 days/month; associated with depression and posttraumatic headache
"Tension-type headache…not primarily caused by muscle tension or stress" — Neuroanatomy through Clinical Cases, 3e
Treatment:
- Acute: NSAIDs (ibuprofen, naproxen), acetaminophen, aspirin
- Non-pharmacologic: Muscle relaxation, biofeedback, regular sleep, stress management
- Chronic/preventive: Tricyclic antidepressants (amitriptyline), lifestyle modification, physical therapy
2. Migraine
Affects ~16% of all headache sufferers; more common in women (3:1 ratio).
Features:
- Location: Unilateral in 2/3 of attacks; can be bilateral
- Quality: Pulsating/throbbing
- Severity: Moderate to severe; often incapacitating
- Duration: 4–72 hours
- Associated symptoms: Nausea, vomiting, photophobia, phonophobia, osmophobia
- Clinical mnemonic (93% PPV): Presence of 2/3 of: Photosensitivity, Incapacitation, Nausea = migraine diagnosis
Subtypes:
- Migraine without aura — most common form
- Migraine with aura — preceded by reversible neurologic symptoms (visual zigzag scintillations, scotoma, sensory changes) lasting 20–30 min
- Chronic migraine — headache on ≥15 days/month
- Status migrainosus — severe migraine lasting >72 hours
- Hemiplegic migraine — rare; unilateral motor weakness as aura; linked to calcium channel gene mutations (CACNA1A)
- Retinal migraine — transient monocular visual loss without headache
- Vestibular migraine — dizziness/vertigo with migrainous features
Triggers: Menstruation, alcohol (red wine), sleep disruption, stress, certain foods (chocolate, aged cheese, smoked meats), bright light, caffeine changes.
Treatment:
| Approach | Agents |
|---|---|
| Mild-moderate acute | NSAIDs, acetaminophen, aspirin + caffeine, antiemetics (metoclopramide, prochlorperazine) |
| Moderate-severe acute | Triptans (sumatriptan, zolmitriptan, rizatriptan) — 5-HT₁B/D agonists; Ergotamine/dihydroergotamine |
| Newer acute agents | Ditans (lasmiditan — 5-HT₁F agonist); Gepants (ubrogepant, rimegepant — CGRP antagonists) |
| Preventive (prophylactic) | Beta-blockers (propranolol, metoprolol), calcium channel blockers (verapamil), anticonvulsants (topiramate, valproate), tricyclic antidepressants (amitriptyline), CGRP monoclonal antibodies (erenumab, fremanezumab) |
| Refractory/chronic | Botulinum toxin type A (Botox) injections — if ≥3 preventive agents failed; greater occipital nerve block |
| Non-pharmacologic | Rest in dark quiet room, cold compresses, hydration, avoiding triggers, regular sleep schedule, biofeedback |
3. Cluster Headache
Relatively rare (~0.1% of headaches) but extraordinarily severe — one of the most painful conditions known.
Features:
- Demographics: Predominantly adult men (age 20–50); male:female ≈ 5:1
- Location: Strictly unilateral — severe, boring/stabbing pain deep behind one eye
- Quality: Non-throbbing, excruciating — often described as a "hot poker in the eye"
- Duration: 15–180 minutes per attack (usually 30–90 min)
- Pattern: Attacks occur 1–8 times/day in "clusters" lasting weeks to months, followed by remission periods of months to years
- Autonomic features (ipsilateral): Lacrimation, conjunctival injection, ptosis, miosis (partial Horner's syndrome), nasal congestion/rhinorrhea, facial flushing, forehead sweating
- Functional neuroimaging shows posterior hypothalamic activation during attacks
- Classified as a Trigeminal Autonomic Cephalalgia (TAC)
Treatment:
| Approach | Agents |
|---|---|
| Acute abort | 100% oxygen inhalation (7–12 L/min × 15 min — highly effective and unique to cluster); Sumatriptan SC or nasal spray; Zolmitriptan nasal spray |
| Preventive (bridge) | Short course of prednisone or ergotamine during cluster period |
| Preventive (maintenance) | Verapamil (first-line), lithium, topiramate, valproate |
| Refractory | Occipital nerve stimulation; sphenopalatine ganglion stimulation |
4. Other Primary Headache Types
| Type | Key Features | Treatment |
|---|---|---|
| Paroxysmal hemicrania | Like cluster but shorter attacks (2–30 min), more frequent, more common in women | Indomethacin (virtually diagnostic response) |
| Hemicrania continua | Unilateral continuous headache with autonomic features | Indomethacin |
| SUNCT/SUNA | Short-lasting unilateral neuralgiform headache with conjunctival injection/tearing (seconds to minutes) | Lamotrigine, IV lidocaine |
| Thunderclap headache | "Worst headache of life," instantaneous onset | Emergency evaluation — rule out subarachnoid hemorrhage first (CT/LP) |
| Cough/exertional headache | Triggered by Valsalva, exercise, sexual activity | Indomethacin; rule out posterior fossa lesion |
| Hypnic headache | Wakes patient from sleep, usually elderly | Caffeine, lithium, indomethacin |
| New daily persistent headache | Abrupt onset, continuous from day one | Treat as migraine or TTH |
SECONDARY HEADACHES — Key Causes to Recognize
Red Flags ("SNOOP4" Mnemonic):
| Flag | Concern |
|---|---|
| Systemic symptoms (fever, weight loss) | Meningitis, temporal arteritis, malignancy |
| Neurologic deficits | Mass lesion, stroke |
| Onset sudden/thunderclap | Subarachnoid hemorrhage |
| Older age (new headache >50) | Giant cell arteritis, tumor |
| Pattern change | Progressive disease |
| Postural change | Intracranial hypertension/CSF leak |
| Papilledema | Raised intracranial pressure |
| Precipitated by Valsalva | Posterior fossa lesion |
Important Secondary Causes:
- Subarachnoid hemorrhage: Thunderclap headache — emergent CT, then lumbar puncture if CT negative
- Meningitis: Headache + fever + neck stiffness + photophobia — LP essential
- Temporal (giant cell) arteritis: Temporal headache + jaw claudication + elevated ESR in patients >50 years → start prednisone 80 mg/day immediately before biopsy to prevent blindness
- Idiopathic intracranial hypertension (pseudotumor cerebri): Obese young women, positional headache, papilledema, pulsatile tinnitus → treat with acetazolamide, weight loss; LP as therapy
- Medication overuse headache (MOH): Paradoxical daily headache from overuse of acute headache medications (>10–15 days/month) — treat by withdrawing the offending agent + preventive therapy
- Post-traumatic headache: Most common symptom after mild TBI; treat symptomatically; image only if high-risk features
Summary: Distinguishing the Big Three
| Feature | Tension-type | Migraine | Cluster |
|---|---|---|---|
| Location | Bilateral | Unilateral (often) | Unilateral (always) |
| Quality | Pressing/tightening | Throbbing/pulsating | Boring/stabbing |
| Severity | Mild–moderate | Moderate–severe | Severe–excruciating |
| Duration | 30 min – days | 4–72 hours | 15–180 min |
| Nausea/vomiting | No | Yes | Rarely |
| Photophobia | No | Yes | No |
| Autonomic features | No | Sometimes | Yes (hallmark) |
| Movement aggravation | No | Yes | Restlessness/agitation |
| Gender predominance | Equal | Female (3:1) | Male (5:1) |
| Acute treatment | NSAIDs | Triptans | O₂, sumatriptan SC |
| Preventive | Amitriptyline | Beta-blockers, topiramate, CGRP MAbs | Verapamil |
Sources:
- Harrison's Principles of Internal Medicine, 22e, Ch. 17 & 441
- Adams and Victor's Principles of Neurology, 12e, Ch. 9
- Neuroanatomy through Clinical Cases, 3e, Table 5.2
- Tintinalli's Emergency Medicine, 9e
- ICHD-3, International Headache Society
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