Overview of Headaches in Adults

How common are headaches in adults?

According to the National Headache Foundation, more than 45 million Americans suffer from chronic, recurring headaches and of these, 28 million suffer from migraines. About 20 percent of children and adolescents also have significant headaches. About 70% of headache sufferers are women.

Headaches are the most common cause of absenteeism from work and school. Migraine sufferers lose more than 157 million work and school days annually because of headache pain.

What are the types of headaches?

A comprehensive headache classification guide was established by the International Headache Society and includes more than 150 diagnostic headache categories.

Based on research, a practical headache classification includes primary and secondary headaches.

Primary headaches

Primary headaches are those that are not the result of another medical condition. The category includes tension, migraine, mixed headache syndrome and cluster headaches.

• Tension headaches: the most common type of primary headaches, accounting for about 90% of all headaches diagnosed. Tension headaches are also called chronic daily headaches or chronic non-progressive headaches. These muscle contraction headaches cause mild to moderate pain and come and go over a prolonged period of time. Tension headaches are not usually associated with sensitivity to light or noise. Tension headaches can be classified as chronic, occurring more than 15 days per month, or episodic, occurring less than 15 days per month.
• Migraines: the second most common type of primary headaches. The exact cause of migraines is unknown, although they are neurovascular in nature and are related to changes in the brain as well as inherited abnormalities in certain areas of the brain. Migraine pain is moderate to severe, often described as pounding, throbbing pain. Migraines can last from 4 hours to 3 days and usually occur 1 to 4 times per month. Migraines are associated with symptoms such as sensitivity to light, noise or odors; nausea or vomiting; loss of appetite; and stomach upset or abdominal pain.
• Mixed headache syndrome: the combination of migraine and tension headaches.
• Cluster headaches: the least common, but most severe, type of primary headache. The pain of a cluster headache is intense and may be described as having a burning or piercing quality that is throbbing or constant. The pain is so severe that most cluster headache sufferers cannot sit still and will often pace during an attack. The pain is located behind one eye or in the eye region, without changing sides. The term "cluster headache" refers to headaches that have a characteristic grouping of attacks. Cluster headaches occur one to three times per day during a cluster period, which may last 2 weeks to 3 months. The headaches may disappear completely (go into "remission") for months or years, only to recur.

Secondary headaches

Secondary headaches, or those that result from another medical condition, include sinus headaches, hormone headaches, chronic progressive headaches or headaches that occur as a result of a head injury, trauma, or more serious condition such as a tumor.

• Sinus headaches: headaches associated with a deep and constant pain in the cheekbones, forehead, or bridge of the nose. The pain usually intensifies with sudden head movement or straining and usually occurs with other sinus symptoms, such as nasal discharge, feeling of fullness in the ears, fever, and facial swelling.
• Hormone headaches: headaches in women are often associated with changing hormone levels that occur during menstruation, pregnancy, and menopause. Chemically induced hormone changes, such as with birth control pills, also trigger headaches in some women.
• Chronic progressive headaches: headaches that get worse and happen more often over time. Chronic progressive headaches are also called traction or inflammatory headaches. These are the least common type of headache, accounting for less than 5% of all headaches. Chronic progressive headaches may be the result of an illness or disorder of the brain or skull.

Are headaches hereditary?

Yes, headaches, especially migraines, have a tendency to run in families. Children who have migraines usually have at least one parent who also suffers from the condition. Headaches also can be triggered by specific environmental factors that are shared in a family’s household, such as exposure to second-hand tobacco smoke, strong odors from household chemicals or perfumes, exposure to certain allergens, or eating certain foods. Stress, pollution, noise, lighting, and weather changes are other environmental factors that can trigger headaches for some people.

People with migraines may inherit abnormalities in certain areas of the brain, as well as the tendency to be affected by certain migraine triggers, such as fatigue, bright lights, weather changes, and others.

What causes headaches?

Headache pain results from signals interacting among the brain, blood vessels and surrounding nerves. During a headache, specific nerves of the blood vessels and head muscles are activated and send pain signals to the brain. It’s not clear, however, why these signals are activated in the first place.

There is a migraine "pain center" or generator in the mid-brain area. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing constriction, followed by the dilation of these vessels and the release of prostaglandins, serotonin and other inflammatory substances that cause the pulsation to be painful. Serotonin is a naturally occurring chemical essential for certain body processes.

Headaches that occur suddenly (acute onset) are usually caused by an illness, infection, cold or fever. Other conditions that can cause an acute headache include sinusitis (inflammation of the sinuses), pharyngitis (inflammation or infection of the throat), or otitis (ear infection or inflammation).

In some cases, the headaches may be the result of a blow to the head (trauma) or, rarely, a sign of a more serious medical condition.

Common causes of tension headaches or chronic non-progressive headaches include emotional stress related to family and friends, work or school; alcohol use; skipping meals; changes in sleep patterns; excessive medication use; tension; and depression. Other causes of tension headaches include eye strain and neck or back strain caused by poor posture.

When chronic headaches become progressive and occur along with other neurological symptoms, they can be the sign of a disease process in the brain (organic cause), such as:

• Hydrocephalus (abnormal buildup of fluid in the brain)
• Infection of the brain
• Meningitis (an infection or inflammation of the membrane that covers the brain and spinal cord)
• Encephalitis (inflammation of the brain)
• Hemorrhage (bleeding within the brain)
• Tumor
• Blood clots
• Head trauma
• Abscess
• Toxins (overexposure to chemicals from certain medications, such as selective serotonin-reuptake inhibitors Prozac^® or Zoloft^®)

How are headaches evaluated and diagnosed?

The good news for headache sufferers is that once a correct headache diagnosis is made, an effective treatment plan can be started.

If you have headache symptoms, the first step is to go to your family physician. He or she will perform a complete physical examination and a headache evaluation. During the headache evaluation, your headache history and description of the headaches will be evaluated. You will be asked to describe your headache symptoms and characteristics as completely as possible.

A headache evaluation may include a CT scan or MRI if a structural disorder of the central nervous system is suspected. Both of these tests produce cross-sectional images of the brain that can reveal abnormal areas or problems. Skull X-rays are not helpful. An EEG (electroencephalogram) is also unnecessary unless you have experienced a loss of consciousness with a headache.

If your headache symptoms become worse or become more frequent despite treatment, ask your family physician for a referral to a specialist. Your family physician should be able to provide the names of headache specialists.

How are headaches treated?

Your family physician may recommend different types of treatment to try or he or she may recommend further testing, or refer you to a headache specialist. You should establish a reasonable time frame with your family physician to evaluate your headache symptoms.

The proper treatment will depend on several factors, including the type and frequency of the headache and its cause. Not all headaches require medical attention. Treatment may include education, counseling, stress management, biofeedback, and medications. The treatment prescribed for you will be tailored to meet your specific needs.

• Headache education includes identifying and recording what triggers your headache, such as lack of sleep, not eating at regular times, eating certain foods or additives, caffeine, environment, or stress. Avoiding headache triggers is an important step in successfully treating the headaches.
• Counseling in the form of one-on-one sessions, group therapy, or support groups can help you identify your headache triggers and teach you useful coping techniques.
• Stress management: To successfully treat headaches, it is important for you to identify what causes or triggers the headaches. Then you can learn ways to cope or remove the stressful activities or events. Relaxation techniques are helpful in managing stress and include deep breathing exercises, progressive muscle relaxation, mental imagery relaxation, or relaxation to music. Ask your health care provider for more information about these techniques.
• Biofeedback: Biofeedback equipment includes sensors connected to your body to monitor your involuntary physical responses to headaches, such as breathing, pulse, heart rate, temperature, muscle tension, and brain activity. By learning to recognize these physical reactions and how the body responds in stressful situations, biofeedback can help you learn how to release and control tension that causes headaches.
• Medications: There are three types of headache medications, including symptomatic relief, abortive, and preventive medications.

What happens after I start treatment?

When your doctor starts a treatment program, keep track of the results and how the treatment program is working. Keep your scheduled follow-up appointments so your doctor can monitor your progress and make changes in the treatment program as needed.

For more information on headaches, read Dr. MaryAnn Mays’ recent blog post on how weather can trigger migraines and what you can do to help prevent or decrease the frequency of your headaches.

References

• National Headache Foundation. Headache-Frequently Asked Questions. www.headaches.org/ Accessed 2/5/2012
• National Institute of Neurological Disorders & Stroke. Headache Information Page. www.ninds.nih.gov/ Accessed 2/5/2012
• Ropper A.H., Samuels M.A. (2009). Chapter 10. Headache and Other Craniofacial Pains. In A.H. Ropper, M.A. Samuels (Eds), Adams and Victor’s Principles of Neurology, 9e. Retrieved February 6, 2012 from www.accessmedicine.com/.