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Headaches are a very common medical problem and a common cause of disability among men and women. Headaches interfere with the ability to work and do daily tasks. Some people have frequent headaches. Other people hardly ever have them.
Causes
Although headaches can be painful and distressing, they are rarely due to a serious condition.
Primary Headache
Disorders:
Most headaches are not caused by another identifiable disorder. Such headaches are called primary headache disorders. They include
Tension-type headaches are the most common type of headache.
Secondary Headache
Disorders:
Less commonly, headaches result from another disorder. Such headaches are called secondary headache disorders. Usually, disorders that cause headaches are not serious. These disorders often affect the eyes, nose, throat, sinuses, teeth, jaws, ears, or neck and are minor or temporary. For example, a dental infection, sinus infection (sinusitis), or a problem with the joint of the jaw (temporomandibular disorder) may cause a headache.
Rarely, headaches are caused by a serious disorder, including the following:
Some of these disorders, such as brain tumors, hemorrhages, hematomas, and intracranial venous hypertension, increase pressure within the skull. In their early stages, many infections, including Lyme disease and Rocky Mountain spotted fever, can cause headaches, as can influenza if severe. These infections can be serious.
Headaches commonly result from withdrawal of caffeine, withdrawal of pain relievers (analgesics) after long-term use, and use of certain drugs that widen blood vessels (such as nitroglycerin ).
Diagnosis
Usually, doctors can determine the type or cause of headaches on the basis of the person's medical history, the characteristics of the headache, and the results of a physical examination. Doctors ask about the characteristics of the headache: frequency, duration, location, severity, and any symptoms that accompany it. Doctors also ask what triggers the headache, what makes it worse, and what relieves it.
The following characteristics may indicate that a serious disorder is the cause of headaches, and people who experience any of them should promptly seek medical attention.
For example, a severe headache with a fever and a stiff neck suggests meningitis—a life-threatening infection of the layers of tissues covering the brain and spinal cord (meninges). A headache that occurs very suddenly and that is more severe than any others the person has experienced may suggest a subarachnoid hemorrhage—bleeding within the meninges, which is often due to a ruptured aneurysm.
Testing:
When doctors suspect a serious disorder, diagnostic tests are usually done. If a tumor, a hemorrhage, or increased pressure within the skull is suspected, computed tomography (CT) or magnetic resonance imaging (MRI) is done immediately.
If meningitis is suspected, a spinal tap (lumbar puncture—see Diagnosis of Brain, Spinal Cord, and Nerve Disorders: How a Spinal Tap Is Done ) is done immediately. A spinal tap may also be done if doctors suspect a subarachnoid hemorrhage or encephalitis. If doctors think that a mass (such as a tumor or abscess) may be present, CT or MRI is done before the spinal tap to determine whether a spinal tap can be done safely. A spinal tap decreases pressure below the brain. If a mass is present, the brain may shift downward and be pressed through one of the small natural openings in the tissues that separate the brain into compartments—a life-threatening disorder called herniation.
Occasionally, blood tests are done to check for a disorder such as Lyme disease. The erythrocyte sedimentation rate (ESR—the rate at which red blood cells settle to the bottom of a test tube containing a blood sample) may be determined to check for giant cell arteritis, which causes inflammation. A high ESR suggests inflammation.
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How Headaches Differ
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Type or Cause
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Characteristics*
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Diagnostic Tests
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Primary (not due to another disorder)
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Cluster
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The pain is severe and piercing. It affects one side of the head and is focused around the eye. The pain lasts 30 minutes to about 1 hour. People with cluster headaches cannot lie down, frequently pace, and sometimes bang their heads. Headaches occur in clusters, separated by periods when no headaches occur. They are usually not worsened by light, sounds, or smells and are not accompanied by nausea and vomiting.
On the same side as the pain, the nose runs, the eye tears, the eye lid droops, and the area below the eye may swell.
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Tests are the same as those for tension-type headaches.
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Migraine
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The pain is moderate to severe. A pulsating or throbbing pain is felt on one side or sometimes on both sides of the head. The pain lasts several hours to days. Headaches may be worsened by physical activity, light, sounds, or smells and are accompanied by nausea, vomiting, and sensitivity to sounds, light, and odors.
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Tests are the same as those for tension-type headaches.
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Attacks can occur for a long period of time, then disappear for weeks, months, or years. Often, people have a sensation that a migraine is beginning. This sensation (called a prodrome) may include mood changes, loss of appetite, and nausea. Attacks may be preceded by temporary disturbances in sensation, balance, muscle coordination, speech, or vision (such as seeing flashing lights and blind spots). These disturbances are called the aura.
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Tension-type
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The pain is usually mild to moderate. It feels like tightening of a band around the head and affects the whole head. The pain lasts 30 minutes to several days. It may be worse at the end of the day. Headaches are not worsened by physical activity, light, sounds, or smells and are not accompanied by nausea and vomiting.
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CT or MRI of the head is occasionally done to rule out other disorders, particularly if the headaches have developed recently or if the symptom pattern has changed.
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Secondary (due to another disorder)
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Brain abscess
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The pain is similar to that caused by a brain tumor. However, if an abscess ruptures, acute meningitis results, causing an intense headache and a stiff neck.
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MRI or CT is done.
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Brain tumor
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Pain is mild to severe and may become progressively worse. It usually recurs more and more often and eventually becomes constant without relief. People often become clumsy, weak, or confused. They may vomit or have seizures.
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MRI is done.
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Encephalitis
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Encephalitis (infection of the brain) can cause headaches.
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MRI or CT and a spinal tap are done.
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People may also have a fever. They may become very drowsy, clumsy, weak, or confused. They may vomit or have seizures. Coma can develop. Some people also have meningitis.
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Eye disorders (such as iritis, glaucoma, and papillitis)
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The pain is moderate or severe and is often worse after using the eyes. It is felt at the front of the head or in or over the eyes.
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An eye examination is done.
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Vision is impaired.
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Giant cell (temporal) arteritis
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A throbbing pain is felt on one side of the head at the temple. The scalp hurts when the hair is combed, and chewing hurts. The arteries in the temples may be enlarged.
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The erythrocyte sedimentation rate (ESR) is determined, and a biopsy of the temporal artery is done.
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Aches and pains may occur, particularly in the shoulders, thighs, and hips. Vision may be lost.
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High blood pressure (hypertension)
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Extremely high blood pressure can cause headaches. The pain is throbbing, occurs in spasms, and is felt at the back or top of the head. Usually high blood pressure does not cause headaches.
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Blood pressure is measured, and blood tests and kidney function tests are done.
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Intracerebral hemorrhage
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The pain may be mild or severe and occurs on one or both sides.
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CT or MRI is done.
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People may become very drowsy, clumsy, weak, or confused. They may vomit or have seizures. Coma can develop.
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Meningitis
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The pain is severe and constant and is felt over the whole head. It travels down the neck, making bending the neck to rest the chin on the chest difficult.
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Blood tests and a spinal tap are done.
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People feel ill, have a fever, and vomit.
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Sinus disorders
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The pain is severe and may be dull or sharp. It is felt at the front of the head. It may begin suddenly and last only a short time, or it may begin gradually and be persistent. It is usually worse in the morning and less severe in the afternoon. Cold, damp weather and lying down make the pain worse.
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CT of the sinuses or endoscopy of the nose may be done.
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People have a runny nose, sometimes with pus or blood. They feel ill, may cough at night, and often have a fever.
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Subarachnoid hemorrhage
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The pain is severe, constant, and widespread. It may reach its peak intensity within a few seconds. Occasionally, it is felt in and around one eye. The eyelid droops. People often describe the headache as the worst ever experienced. They may briefly lose consciousness.
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MRI or CT is done. If the results are negative, a spinal tap is done.
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Some people are sleepy, confused, and hard to rouse. Others are restless. Later, the neck may become stiff, with a continuing headache and often with vomiting, dizziness, and low back pain.
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Subdural hematoma
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The pain is mild to severe and intermittent or constant. It can be felt in one spot or over the whole head and travels down the neck.
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MRI or CT is done.
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People may feel sleepy or become confused or forgetful.
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Other disorders if they affect the brain (such as cancer, cryptococcosis, sarcoidosis, syphilis, and tuberculosis)
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The pain may be mild or severe and dull or sharp. It is felt over the whole head.
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A spinal tap and MRI are done.
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People whose headache is caused by one of these disorders have a moderate fever and other symptoms of the disorder.
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*One, some, or all of the characteristics listed may be present.
CT = computed tomography; MRI = magnetic resonance imaging.
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Last full review/revision April 2008 by Stephen D. Silberstein, MD
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