The Medical Consumer's Advocate

Headache

Douglas Hoffman, M.D., Ph.D., August 1998

Synonyms: migraine, cluster, thunderclap, ice pick headache; cephalgia; neuralgia

 

Contents

Do I need a doctor?

Conservative measures for a new headache.

What your doctor needs to know.

What to expect from your doctor.

But what should your doctor do for you?

The differential diagnosis of headache.

Disclaimer: This information is meant to improve the interaction between you and your doctor.It is NOT meant to replace this interaction!There is no substitute for a history and physical examination administered by a competent physician.If you inappropriately use this information to treat yourself, you may be endangering your health.

Do I need a doctor?

Are your headaches limiting your ability to do your job? Are they interfering with your ability to be a good parent or spouse? Have you had a hard time controlling your headaches with over the counter medications, or do you find yourself continuously having to take such medications? Are your headaches limiting your enjoyment of life? If the answer to any of these questions is yes, you should see a doctor.

Headache can also be a symptom of a more serious medical problem. If any of the following circumstances are true, you should see a doctor as soon as possible.

Danger Signs

• "The worst headache of my life!"

• Headaches are associated with one or more new neurologic symptoms (muscle weakness, memory problems, sleepiness, confusion, incoordination, dizziness, changes in sensation such as areas of numbness or hypersensitivity, changes in vision or of the other special senses, seizures, and so forth).

• Headaches have begun after the age of 40.

• Headaches have become progressively more severe with time.

• A chronic headache which has suddenly changed in its quality.

• A new, severe headache which began abruptly after sex, straining (e.g., with a bowel movement), exertion, or cough.

• Headache that is associated with fever, sensitivity to light, neck pain or stiffness.

• Acute point tenderness anywhere in the face, neck or scalp.

• Other medical problems are present, such as high blood pressure, recent weight loss, chronic fatigue, muscle and joint pains.

Wondering how to use this information?

Refer to Symptom Guide Help for a bit of advice.

 

 

Conservative measures for new onset headache

(none of the above symptoms are present):

First, read Do I need a doctor? to determine whether it is a good idea for you to attempt to treat yourself.

For the new onset headache, ask yourself what in your life is different. Are you under an unusual amount of stress? Have your sleeping habits changed? Have you begun a new exercise program? Are you eating different foods than usual? Either at work or at play, are you engaging in any new activities (e.g., ones which would provoke eye strain or neck strain)? Are you taking any new medications, have you changed dosage on a medication, or stopped taking a medication?

These questions could lead you to an easy (and hopefully correctable) explanation for your headache.Try to eliminate or modify factors that may have caused the headache, so that it does not become a chronic problem.
To treat the immediate problem: before popping some over the counter medication, first try a bit of relaxation. If you are involved in some activity that is placing strain on your neck or eyes, take a short (or long!) break, if possible. Take a hot shower, lie down, close your eyes, and focus on your breathing. Sleep it off, if you can. If a spouse or friend is available, you might have him/her massage the muscles of your neck and the lower part of your scalp.

Over the counter medications for headache.

Most people already know what does or does not work for their headaches.Usually, nonprescription headache medications are based on aspirin, acetaminophen (Tylenol) or ibuprofen (Motrin or Advil).Some headache medications contain one of these analgesics combined with antihistamines and/or decongestants ("cold formulas") and some are combined with caffeine.Taking caffeine for a headache only makes sense if your headache is due to caffeine withdrawal, and this is something that you should be able to figure out for yourself!Cold formulas are fine, but I prefer (for myself and for my patients) to use the medications separately so that I can control dosage and rate of administration.

Follow the dosage recommendations and do not exceed the recommended maximum dose.Each of the analgesics listed above can be very toxic, even lethal, if taken as an overdose.

What your doctor needs to know.

Skin is probably the most commonly injured organ.Skin is unique in that painful injuries are very well-localized.(In other words, if you are stuck with a pin, you generally can point to the exact location of the injury.)Consequently, we become accustomed to assuming that pain arises in the painful site.In fact, other organs do not localize pain well, so the location of the pain can sometimes be misleading.Headache is no exception; as discussed below (the differential diagnosis of headache) many different structures in the head and neck can, when injured, cause headache. If you can provide you doctor with a very thorough history, you will help him determine the source of your headache.

At a minimum, your doctor will need to know:

• What is the pain like? (Dull, stabbing, burning, sharp, throbbing, and so forth.)

• How severe is the pain? (Note that "really bad" has very little information content.On the other hand, phrases such as "the worst headache of my life", "so bad it woke me up last night", or "so bad I can't get any work done" help your doctor understand the severity of your headache.)

• Where does it hurt? (Despite the comments above, the location of the headache can give some clues as to the nature of the problem.)

• For how long have you been having these problems?

• How long do the headaches last?

• What is the time course of each headache?(For example, some headaches have a sudden onset, while others begin slowly, build to a peak, and then gradually fade.)

• Are there any things (activities, medications, etc.) which provoke, worsen or relieve the headache?

The answers to these questions may indicate the correct diagnosis.Additional history, however, is sometimes essential.If answers to any of the following questions are positive, you ought to share this information with your doctor.

The questions below are specific to the headache itself.Your doctor will also need to know your general medical history.This includes: any problems for which you are under a doctor's care; problems for which you take medications; a list of all of your medications, including over the counter drugs, vitamins and herbal remedies; a list of the operations you have had; whether you are allergic to any medications; whether you drink alcohol, smoke tobacco, or use other drugs; whether there are any illnesses that run in your family.

• Are any danger signs present?

• Have you ever suffered any head trauma (concussion, skull fracture, blow to the head resulting in loss of consciousness, etc.)?

• Have you noticed a change in your vision (blurry vision, blind spots, double vision, "wavy lines", etc.)? Do your eyes hurt? Have you recently changed the prescription on your glasses or contact lenses?

• Have you noticed a change in your hearing (decreased hearing, difficulty understanding speech in a noisy room, ringing in your ears, etc.)?

• Have you had problems with dizziness, inability to smell or taste, difficulty speaking or swallowing, difficulty or pain chewing?

• Do you have pain anywhere else in your head and neck?

• Have you ever had a seizure or lost consciousness (fainted) for any reason?

• Have you developed any weakness in your hands, arms, legs or trunk?

• Have you developed a new tremor?

• On your skin, have you developed any areas that are numb, tingling, or hypersensitive?

• Do you seem to be more forgetful than usual?

• Do you seem to be more clumsy or uncoordinated than usual?

• Do you have any new difficulty standing or walking?

• Are you unable to breathe through your nose?

• Do you have thick mucus in the back of your throat when you wake up?

• Are you unable to move your neck in the usual way?

• Do you have any loose or painful teeth?Do your teeth no longer meet in their usual way?Does your jaw joint "click" or hurt when you open and close your mouth?

• Do you have, or have you ever had, cancer?

• Have you recently experienced fevers, night sweats, chills, muscle or joint aches, an unusual degree of fatigue, or an unexplained weight loss?

What to expect from your doctor.

It is critical that your doctor obtain an excellent history.He should give you the time to tell your story, and he should ask you whatever questions are necessary to fill in any obvious gaps.Try not to diagnose yourself ahead of time, as this may cause you to "lead" the doctor.In other words, he may agree with your diagnosis because you have skewed your history to fit that particular diagnosis.Patients are often right, but they are not always right.Simply provide him with all of the relevant information (as described above) and let him think about it.

Physical examination is unhelpful for most of the common forms of headache (e.g., migraines or tension headaches).In certain less common situations, physical examination is essential.For example, a patient with temporal arteritis may have a hard, tender artery just below the skin of the temple, which the doctor may detect if he gently palpates this region.For headaches due to eye, nose, sinus, ear, jaw or tooth problems, examination of the suspicious area may be very informative.Neck pain and stiffness are important signs that your doctor may detect on examination.

It is impossible to describe a physical examination that would be appropriate for all patients.Your doctor will be guided by the history which you have provided and will tailor the examination accordingly.

But what should your doctor do for you?

If any of the danger signs are present and there is no obvious (and innocent) explanation for the headache, your doctor should give you an appropriate referral (usually, this is a referral to a neurologist).If it is likely (based on the history and physical examination) that your headache is due to a problem with your eyes, ears, nose, sinuses, teeth or jaws, then your doctor should refer you to the appropriate specialist.(Of course, if your doctor is able to diagnose your problem and has the ability to treat your problem, referral to a specialist may not be necessary.)In some cases, further studies may be indicated.These may include blood tests, a CT scan (CAT scan) of the head, or an MRI scan of the head.

The differential diagnosis of headache

This list is not intended to fuel the flames of hypochondria.Rather, it is hoped that the material in this section will stimulate discussions between you and your doctor, particularly if your headache has proven difficult to diagnose and treat.

Headache is usually a consequence of inflammation and/or physical distortion of structures located in the head.Dental infection, temporomandibular joint (jaw joint) arthritis, and sinusitis are 3 examples of inflammatory diseases that can cause headache.Dilation of blood vessels inside or outside the skull can occur after ingestion of alcohol or certain foods (e.g., foods containing MSG or nitrites), and this dilation can be associated with a severe headache; this is an example of headache due to physical distortion of a normal anatomic structure.Below, the differential diagnosis of headache is organized by anatomic site.Headache can also be a consequence of a more generalized medical condition, and these headaches are listed below under Systemic problems.

As you read the list, you will note that with many of these diagnoses, headache "should not" be the most prominent symptom; common sense would suggest that some other symptom would lead your doctor to the correct diagnosis.Nevertheless, occasionally headache is the most prominent symptom, and the doctor must look carefully at other symptoms (ones which the patient may consider to be quite minor) to determine the source of the headache.

• Skin. Any infectious or inflammatory disorder affecting the skin of the face and scalp; trauma (e.g., sunburn).

• Jaw. Dental infection, gum disease, temporomandibular joint (jaw joint) problems (e.g., arthritis), "myofascial pain syndrome".

• Mouth and throat. Sore throat (tonsillitis, pharyngitis).

• Nose. "Contact point" headache (caused by tissues within the nose touching and putting pressure upon one another), nasal foreign body, sinus infection.

• Eyes. Eye strain due to uncorrected or poorly-corrected vision problems, acute glaucoma, infection or inflammation.

• Ears. Middle ear infection, ear canal infection (swimmer's ear).

• Blood vessels. Inflammatory disease (e.g., temporal arteritis), blood vessel dilation
  (following comsumption of certain foods; dilation may also play a role in migraine).

• Skull. Trauma, infection (osteomyelitis), tumor (e.g., multiple myeloma).

• Neck. Cervical spine arthritis, tendinitis, ligament injury (e.g., whiplash).

• Nerves. Persistent pain may be due to compression of nerves by tumor or trauma, inflammation (e.g., optic neuritis), infarction (interrupted blood flow to the nerve; e.g., diabetic neuropathy), infection (e.g. herpes zoster, also known as shingles, and the associated problem of postherpetic neuralgia).Intermittent brief, sharp and severe pains suggest a cranial nerve neuralgia syndrome such as trigeminal neuralgia.

• Intracranial structures (the brain and its membranes and blood vessels).Trauma (e.g. chronic subdural hematoma), vascular problems (e.g., arteriovenous malformations, subarachnoid hemorrhage), infection (e.g., meningitis), tumor.

• Please note that, although tumor/cancer was not specifically mentioned in all cases above, this is certainly an important part of the differential diagnosis for each region.

• Headaches of unclear origin. This includes the most common headaches: migraine, cluster headache, and tension headache.Headaches related to cough, exercise, or sexual activity are similarly of unclear origin.

• Systemic problems. High blood pressure, chronic lung disease, hypothyroidism, other glandular disorders, systemic inflammatory conditions (e.g. arthritis or polyarteritis).Infection, especially viral infection (e.g. the common cold) can also cause headache.

• Medications. Withdrawal from chronic use of painkillers, corticosteroids or caffeine; chronic use of ergotamine (a medicine used to treat migraine), birth control pills.