Aneurysm/Subarachnoid Hemorrhage
Symptoms: A sudden (less than 5 minutes), unbearable headache, double vision, rigid neck. Individual may rapidly become unconscious.
Precipitating Factors: Caused by weakness or bulge in blood vessel at the base of the brain. May rupture or allow blood to leak leading to a hemorrhagic stroke. If aneurysm is discovered early, treat with surgery if needed.
Treatment and Prevention: If aneurysm is discovered early, treat with surgery if needed.
Important: Headache caused by an aneurysm or subarachnoid hemorrhage is a medical emergency. A sudden, severe headache, particularly when accompanied by neurological symptoms, requires immediate evaluation. Call 911 or seek emergency medical care without delay.
Caffeine-Withdrawal Headache
Symptoms: Bilateral, pulsating occurring within ≤ 24 hours of caffeine withdrawal.
Precipitating Factors: Caffeine consumption
Treatment and Prevention: Large changes in your daily caffeine intake can trigger withdrawal headaches. If you consume caffeine, aim for no more than 200 mg per day and have a similar amount at approximately the same time each day.
Cervicogenic Headache
Symptoms: Pain on one side of the head or face, stiff neck, pain around the eyes, neck, shoulder, and arms, nausea, blurred vision, sensitivity to light and sound.
Precipitating Factors: Injury to the neck, malformations of the cervical vertebrae, arthritis of the upper spine
Treatment: Treatment varies depending on the severity of symptoms, non-steroidal anti-inflammatories (aspirin or ibuprofen), nerve blocks, physical therapy, transcutaneous electrical nerve stimulation (TENS), neuromodulation surgery. Without treatment, a cervicogenic headache can become debilitating.
Diagnosis Consideration: Neck pain is a frequent symptom of migraine, affecting roughly 70% of people living with the disease. Cervicogenic headache is a distinct condition in which pain originates from structures in the neck, making a thorough evaluation important for an accurate diagnosis.
Chronic Migraine
Symptoms: Headache occurring more than 15 days a month, for more than 3 months, with attacks typically lasting 4 or more hours, which have the features of migraine on at least 8 days per month.
Precipitating Factors: Medication Overuse Headache (MOH) and poorly controlled episodic migraine. Can occur without MOH and be associated with major life events, obesity, ineffective migraine control with acute medications.
Treatment and Prevention: After drug withdrawal, headaches will either revert to episodic or remain chronic. OnabotulinumtoxinA, gepants, and CGRP monoclonal antibodies have been approved for prevention of use in chronic migraine.
Acute attacks can be treated with triptans, gepants, NSAIDS, and combination analgesics. Limit use of acute treatment to less than 2 days per week to reduce risk of MOH. Avoid opioids and butalbital whenever possible.
Cluster Headache
Symptoms: Rapid onset, excruciating pain in vicinity of eye. Tearing and redness of eye; runny, congested nose; flushing of face. Pain may last for 15 minutes to 3 hours if untreated. Repeated daily attacks for weeks, may disappear for months or years. More common among men (3:4.1 ratio), and frequently appears between ages 20-50.
Precipitating Factors: May be inherited in 5% of cases. During cluster, attacks may be provoked by alcohol.
Treatment and Prevention: Prevent with use of verapamil, often with divalproex, corticosteroids are very effective at high doses but only used short term. Galcanezumab approved for prevention. Attacks should be treated with oxygen inhalation or subcutaneous sumatriptan.
Exertional Headache
Symptoms: Often, abrupt onset of headache. Generalized head pain of short duration (minutes to 1 hour); may last up to 48 hours.
Precipitating Factors: Triggered by strenuous physical exertion (running, jumping, orgasm), or passive exertion (coughing, sneezing, or straining for a bowel movement).
Treatment and Prevention: Should always receive a neurological evaluation and brain imaging. Most commonly treated with indomethacin or propranolol. Pretreatment with triptans or ergotamines may be effective.
Fasting Headache
Symptoms: Frontal location, with diffuse, non-pulsating pain of mild-to-moderate intensity.
Precipitating Factors: Caused by fasting > 16 hours.
Treatment and Prevention: Headache should resolve ≤ 72 hours after resumption of food intake.
Eat multiple small meals daily.
Giant Cell Arteritis
Symptoms: A burning or soreness of the scalp, commonly associated with tenderness of temporal arteries. Often, jaw pain with sustained chewing. Sudden and irreversible visual loss can occur. Patients generally ≥ 50 years.
Precipitating Factors: Vascular disease characterized by inflammation of the blood vessels.
Treatment and Prevention: Treat as soon as diagnosis suspected with oral corticosteroids while awaiting biopsy. after diagnosis. Detected by erythrocyte sedimentation rate (ESR) and C-reactive protein test. Confirmed by biopsy of temporal artery.
Hangover Headache
Symptoms: Migraine-like symptoms of throbbing pain and nausea, but it is not localized to one side.
Precipitating Factors: Alcohol, which causes dilation and irritation of the blood vessels of the brain and surrounding tissue.
Treatment: Liquids (including broth); consumption of fructose (honey, tomato juice are a good source)
Prevention: Drink alcohol only in moderation
Headache Attributed to Infection
Symptoms: Diffuse, moderate-to-severe pain caused by acute infection, accompanied by fever.
Precipitating Factors: Caused by infections
Treatment and Prevention: Treat with aspirin, acetaminophen, NSAIDs, antibiotics as needed.
Hemiplegic Migraine
Symptoms: Stroke-like symptoms- Severe throbbing pain, often on one side of the head, numbness, weakness or paralysis on one side of the body, nausea, vomiting, dizziness, loss of balance, speech difficulties, visual disturbances, auras, sensitivity to light, sound, and smell.
Precipitating Factors: Hemiplegic migraine has a strong genetic component.
Treatment: Once confirmed, treatment should consist of dietary modification to avoid triggers, regular exercise and sleep, and dietary supplementation, such as magnesium. Topiramate, valproic acid, and calcium channel blockers have shown the best pharmacologic results. Triptans must be avoided to prevent severe complications. Such care is best provided under the supervision of a multidisciplinary headache clinic or a specialized neurologist.
Prevention: Preventive medications, dietary modification to avoid triggers, regular exercise and sleep
Hunger Headache
Symptoms: Pain strikes just before mealtime. It is caused by muscle tension, low blood sugar, and rebound dilation of the blood vessels, oversleeping, or missing a meal.
Precipitating Factors: Strenuous dieting or skipping meals
Treatment: Regular, nourishing meals containing adequate protein and complex carbohydrates
Prevention: Regular, nourishing meals containing adequate protein and complex carbohydrates
Hypertension Headache
Symptoms: Most severe in the morning and diminishes throughout the day.
Precipitating Factors: Severe hypertension ≥ 200mm Hg systolic and ≥ 110 diastolic. Modest increases in blood pressure do not cause headache.
Treatment and Prevention: To prevent, keep blood pressure under control. Treat with appropriate blood pressure medication.
Menstrual Migraine
Symptoms: Migraine that occurs shortly before, during, or immediately after menstruation or at mid-cycle (at time of ovulation).
Precipitating Factors: Hormonal fluctuations.
Treatment and Prevention: Preemptively manage migraine attacks with mini-prophylaxis or pulse therapy with triptans, Remegepant may be effective to treat and/ or prevent. NSAIDs immediately before and during menstrual period. Treat as for migraine. Hysterectomy does not cure menstrual headaches.
Migraine without Aura
Symptoms: Moderate to severe pain; commonly associated with sensitivity to light and sound; nausea common. Worse with activity; attacks last 4 to 72 hours. One-sided throbbing pain.
Precipitating Factors: Certain foods, hormones in women, excessive hunger, changes in altitude, weather, bright lights, odors, and emotional stress. Hereditary component.
Treatment and Prevention: Prevent with biofeedback, some beta-blockers ex. propranolol, timolol, some antiepileptic drugs ex topiramate, divalproex sodium, or some antidepressants amitriptyline, nortriptyline. CGRP monoclonal antibodies recently available for prevention.
Acute treatment includes triptans, NSAIDs ex Cambia, naproxen, aspirin, can also include: ice packs, combination products containing caffeine, ergotamine, DHE, triptans, or analgesics and neuromodulation devices.
Supportive care with icepacks and bedrest. For prolonged attacks steroids and occipital nerve blocks may be helpful.
Migraine with Aura
Symptoms: Similar to migraine without aura, attacks often preceded by sensory changes such as vision, tingling and numbness lasting less than an hour.
Precipitating Factors: Same as migraine without aura.
Treatment and Prevention: Prevent as with migraine without aura. Once pain has begun, treat as with migraine without aura.
New Daily Persistent Headache
Symptoms: This headache can best be described as the rapid development (less than three days) of unrelenting headache, and typically presents in a person with no past history of headache.
Precipitating Factors: Typically NDPH does not evolve from migraine or episodic tension-type headache. NDPH begins as a new headache. It may be the result of a viral infection but cause is generally unknown.
Treatment and Prevention: In some cases NPDH can resolve on its own within several months. Other cases persist and are more refractory. NPDH does not respond to traditional options. Migraine preventive agents can be tried.
Post-Traumatic Headaches
Symptoms: Localized or generalized pain following trauma. May be accompanied by dizziness, difficulty concentrating, nervousness, personality changes, and insomnia. Can mimic migraine or tension-type headache symptoms.
Precipitating Factors: Pain can occur after relatively minor traumas.
Treatment and Prevention: Possible treatment with anti-inflammatory drugs, propranolol, or biofeedback.
Sinus Headache
Symptoms: Commonly associated with fever and colored nasal drainage. Most self-diagnosed cases are actually migraine.
Precipitating Factors: Infection, nasal polyps, anatomical deformities, such as a deviated septum, that block the sinus ducts. Most cases are actually migraine rather than sinus headache.
Treatment and Prevention: Treat with antibiotics if due to bacteria, nasal rinses, decongestants, surgical drainage if necessary.
Temporo-Mandibular Joint Dysfunction (TMD) Headache
Symptoms: Pain in temples often associated with a click over the temporomandibular joints.
Precipitating Factors: Pathology can be in the joint or in the muscles of chewing.
Treatment and Prevention: Relaxation, biofeedback, use of bite plate. In extreme cases, correction of malocclusion, nerve blocks.
Tension-Type Headache
Symptoms: Dull, non-throbbing pain, frequently bilateral, associated with tightness of scalp or neck. Degree of severity remains constant and should not be disabling
Precipitating Factors: Stress, depression. When associated with migraine, most are actually mild migraines.
Treatment and Prevention: Prevent with avoidance of stress, biofeedback, relaxation techniques, and antidepressants. Treat with aspirin, acetaminophen, ibuprofen, and naproxen sodium. Combination with caffeine may enhance the action of the analgesics.
Trigeminal Neuralgia (Tic Douloureux)
Symptoms: Sharp, lancinating pain in the face. No pain between jabs. More common in women after age 55.
Precipitating Factors: Often triggered by touching the face. Often caused by abnormal artery loop compressing the trigeminal nerve.
Treatment and Prevention: Treat with some anticonvulsants. Neurosurgery, if appropriate, to release the artery loop. Blocking trigeminal nerve by various means can be helpful.
Thunderclap Headache
Symptoms: Sudden and severe pain that may be accompanied by nausea, vomiting, fever, seizure speech problems, weakness, confusion, visual disturbances.
Precipitating Factors: Thunderclap Headache may be due to a benign syndrome or a potentially life-threatening condition.
Treatment: Since the nature of the headache by itself cannot allow the distinction between benign and serious causes, it is essential to seek out an emergency medical evaluation if the onset of a headache is sudden and severe.
Prevention: None
Tumor Headache
Symptoms: Progressive, localized pain that is worse in the morning and aggravated by coughing or bending forward. Pain may be diffuse, associated with nausea and/or vomiting, and occur in attack-like episodes.
Precipitating Factors: Cause of tumor is usually unknown.
Treatment and Prevention: Treat tumor with surgery or chemotherapy, and associated symptoms with corticosteroids.