Acute and Chronic Headaches/Migraine

Headache occurs when you feel pain in any region of your head; it may happen on one or both sides of your head, be isolated in a specific location, radiate across your head from a central point or you may feel like your entire head is in a vise. The pain from a headache may be sharp and throbbing or a dull ache. The headache symptoms may happen gradually or suddenly and they can be over in as little as an hour or last for several days. Most headaches are not life threatening, but some may require emergency care .

A migraine headache is often on one side of the head and can be felt as an intense throbbing or a pulsing sensation and is commonly accompanied by nausea, vomiting or extreme sensitivity to light and sound. The intensity and symptoms of a migraine headache varies from person to person.

Headaches are classified into two types: primary and secondary. Primary headaches are not caused by underlying conditions, whereas secondary headaches are.

Primary Headaches
Headaches are categorized as primary if they are not the result of an underlying disease. The most common forms of primary headaches include cluster headaches, migraines and tension headaches.

Cluster Headaches
Cluster headaches are primary headaches that occur in cyclical patterns or clusters and are one of the most painful types of headache. Cluster headaches are less common than migraines or tension headaches and usually bring severe pain (sometimes described as ‘stabbing’ pain) behind one eye, and may be accompanied by redness and nasal congestion. Patients with cluster headaches may also notice paleness in their face, perspiration, swelling around the affected eye, a drooping of the affected eye's lid or a general feeling of restlessness.

Cluster headaches often wake you up from a sound sleep. You may experience bouts of frequent attacks (called cluster periods) that can last from weeks to months; these are typically followed by remission periods.

Abnormalities in the hypothalamus are likely to play a role in cluster headaches. Men are more likely than women to suffer from cluster headaches.

As painful as they are, cluster headaches are usually not life threatening and are somewhat rare, affecting less than one in a 1,000 headache sufferers.

Migraines are primary headaches that frequently involve severe pain on one side of the head, and may be accompanied by nausea, vomiting and sensitivity to light and sound. Migraine attacks can be debilitating and last anywhere between an hour and several days. Migraines may be preceded by sensory warnings (called an aura) such as flashes of light, blind spots in your vision and tingling in your arms and legs.

Migraines typically progress through four stages:

  • The prodrome occurs one to two days before the migraine and may signify the oncoming attack with symptoms of constipation, depression, food cravings, hyperactivity, irritability, a stiff neck and excessive yawning.
  • The aura may happen right before or during the headache and usually consists of visual disturbances such as flashes of light, although auras may also manifest as touch sensations or movement or speech disturbances. Most people experience migraines without the aura.
  • The attack (or headache) part of a migraine lasts anywhere from 4 to 72 hours and may produce a throbbing pain most often on one side of your head or behind your eye, sensory sensitivity, nausea and vomiting, blurred vision and lightheadedness.
  • The postdrome phase occurs after the attack is over and it may leave you feeling weak, although some people feel euphoric.

A migraine sufferer may not experience all of these stages.

Genetics and environment seem to be contributing factors to migraines and include such elements as hormonal changes in women. In addition, aged or salty processed foods, some food additives (such as artificial sweetners and MSG), alcohol and caffeine, stress, overwhelming sensory stimuli, getting too little or too much sleep, and even weather and medications, such as oral contraceptives and vascular dilators may contribute as migraine triggers.

Women are three times more likely to have migraines than men, and by the age of 40, most people who have a family history or are prone to migraines will have experienced their first migraine attack.

Tension Headaches
A tension headache, the most common primary headache, is typically a diffuse headache of mild to moderate pain; it is described as feeling like you have a tight band around your head. You may feel some tenderness in your scalp, neck and shoulder muscles. Your tension headache may be episodic (last from 30 minutes to a week and occur less than 15 days a month for at least 3 months) or chronic (last hours and be continuous and occur 15 or more days a month for at least 3 months).

The causes of tension headaches are unknown but stress may be a trigger. Women are slightly more susceptible to tension headaches, but more than 70 percent of all people will experience a tension headache in their lifetimes.

Secondary headaches
Secondary headaches are more rare but also more serious than primary headaches. The source of these headaches is often due to serious health issues or other underlying conditions, which can include brain aneurysms or tumors, dysfunctions of the spinal fluid or inflammatory diseases.

To resolve or manage the secondary headache, doctors need to understand and diagnose the source of the headache. Though it may not be life threatening, the cause of the headache can be serious and therefore immediate attention is needed for an early diagnosis and to help treat a secondary headache. Doctors at Houston Methodist have the specialized expertise to identify these underlying causes so they can be treated promptly.

Thunderclap Headaches
Thunderclap headaches arrive in a burst of severe pain and often peak within 60 seconds and can start fading after an hour; however, some are known to last a week or more. You may experience nausea and vomiting.

These headaches are uncommon, but they can be a warning sign of such life-threatening conditions as bleeding in and around the brain, loss of cerebrospinal fluid, meningitis or encephalitis or a severe spike in blood pressure, so treat this type of headache as an emergency and call 911.

Seek emergency care
If you experience a thunderclap headache or headache with other symptoms such as fever, stiff neck or confusion, it can be a sign of a serious condition such as stroke, brain tumors, aneurysms, meningitis or encephalitis. Call 911 immediately.

Always seek emergency care if you have a severe headache in combination with other serious symptoms:
  • An abrupt, severe headache with no discernable cause
  • Headache with a fever, nausea or vomiting, neck stiffness, cognitive confusion, seizures, fainting spells, numbness or difficulty speaking
  • Headache after a head injury
  • Headache that gets worse over days and changes in pattern

Diagnosis of Primary and Secondary Headaches

Primary headaches
Diagnosing primary headaches begins with a review of the patient's medical history, description of symptoms and the pattern of headaches, as well as a thorough physical exam to determine the type of headache and how to treat it. The doctor may suggest imaging, blood tests and neurological tests to better understand the patient’s condition and to eliminate other potential causes of the headache.

Secondary headaches

For secondary headaches that are not life threatening, our physicians will take the patient’s medical history, a description of symptoms and the pattern of headaches and perform a thorough physical exam to determine the type of headache and how to treat it.

For a thunderclap headache, the emergency room team will probably use CT and MRI scans to image cross-sections of the patient’s brain to identify the problem. A lumbar puncture (spinal tap) may also be ordered to test the cerebrospinal fluid for signs of bleeding or infection. At Houston Methodist, we may enhance the MRI scan by performing an angiography, injecting dye into the patient’s system to get a clearer picture of any bleeding in the brain.

Treating Primary and Secondary Headaches
In the presence of any of the signs or symptoms noted above, a diagnostic assessment may include blood tests, brain scans, a lumbar puncture or referral to another specialist.

Our team will treat migraines much in the same way we resolve cluster headaches, focusing on lessening the severity of pain and preventing the next attack. We will recommend pain relievers (ibuprofen), triptans (sumatriptan), ergot (dihydroergotamine), anti-nausea medications (chlorpromazine), opioids (codeine) and glucocorticoids (prednisone) to help relieve migraine symptoms.

To prevent or reduce the frequency of your migraines, we may suggest cardiovascular drugs (ACE inhibitors, beta blockers and calcium channel blockers), antidepressants, anti-seizure drugs, pain relievers and injections of botulinum toxin (Botox®).

We will encourage you to get just the right amount of sleep (not too much or too little), try muscle relaxation exercises and keep a headache diary to discover what triggers your migraines.

Tension Headaches
Tension headaches rarely require medical attention. We would suggest managing these with over-the-counter pain relievers (including those that combine the pain reliever with caffeine or sedative) and triptans.

Secondary Headaches
To treat secondary headaches, doctors must first identify their underlying cause and recommend an immediate course of treatment for that disease or condition. Because the possible causes of secondary headaches include life-threatening conditions such as brain tumors or aneurysms, prompt diagnosis and treatment is essential. Once the underlying cause is treated, your physician at Houston Methodist will continue to monitor your condition through CT scans or other diagnostic tests, as needed, to confirm both headache and source of the headache are successfully managed, resolving any life-threatening condition.

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