Headache

A headache is pain or discomfort in the head, scalp, or neck. Serious causes of headaches are extremely rare. Most people with headaches can feel much better by making lifestyle changes, learning ways to relax, and occasionally by taking medications. The most common headaches are probably caused by tight, contracted muscles in your shoulders, neck, scalp, and jaw. These are called tension headaches. They are often related to stress, depression, or anxiety. Overworking, not getting enough sleep, missing meals, and using alcohol or street drugs can make you more susceptible to them. Headaches can be triggered by chocolate, cheese, and monosodium glutamate (MSG). People who drink caffeine can have headaches when they don't get their usual daily amount.

Causes

A headache is pain or discomfort in the head, scalp, or neck. Serious causes of headaches are extremely rare. Most people with headaches can feel much better by making lifestyle changes, learning ways to relax, and occasionally by taking medications.

The most common headaches are probably caused by tight, contracted muscles in your shoulders, neck, scalp, and jaw. These are called tension headaches. They are often related to stress, depression, or anxiety. Overworking, not getting enough sleep, missing meals, and using alcohol or street drugs can make you more susceptible to them. Headaches can be triggered by chocolate, cheese, and monosodium glutamate (MSG). People who drink caffeine can have headaches when they don't get their usual daily amount. 

Other common causes include:

  • Holding your head in one position for a long time, like at a computer, microscope, or typewriter
  • Poor sleep position
  • Overexerting yourself
  • Clenching or grinding your teeth

Types of Headaches and Causes

Tension headaches tend to be on both sides of your head. They often start at the back of your head and spread forward. The pain may feel dull or squeezing, like a tight band or vice. Your shoulders, neck, or jaw may feel tight and sore. The pain is usually persistent, but does not get worse with activity. 

Migraine headaches are severe headaches that usually occur with other symptoms such as visual disturbances or nausea. The pain may be described as throbbing, pounding, or pulsating. It tends to begin on one side of your head, although it may spread to both sides. You may have an "aura" (a group of warning symptoms that start before your headache). The pain usually gets worse as you try to move around. For more information on this type of headache, see: migraine. 

Other types of headaches:

  • Cluster headaches are sharp, extremely painful headaches that tend to occur several times per day for months and then go away for a similar period. They are far less common.
  • Sinus headaches cause pain in the front of your head and face. They are due to inflammation in the sinus passages that lie behind the cheeks, nose, and eyes. The pain tends to be worse when you bend forward and when you first wake up in the morning. Postnasal drip, sore throat, and nasal discharge usually occur with these headaches.

Headaches may occur if you have a cold, the flu, fever, or premenstrual syndrome. 

If you are over age 50 and are experiencing headaches for the first time, a condition called temporal arteritis may prove to be the cause. Symptoms of this condition include impaired vision and pain aggravated by chewing. There is a risk of becoming blind with this condition. Therefore, it must be treated by your doctor right away. 

Rare causes of headache include:

  • Brain aneurysm - a weakening of the wall of a blood vessel that can rupture and bleed into the brain
  • Brain tumor
  • Stroke or TIA
  • Brain infection like meningitis or encephalitis

Home Care Suggestions 
Keep a headache diary to help identify the source or trigger of your symptoms. Then modify your environment or habits to avoid future headaches. When a headache occurs, write down the date and time the headache began, what you ate for the past 24 hours, how long you slept the night before, what you were doing and thinking about just before the headache started, any stress in your life, how long the headache lasts, and what you did to make it stop. After a period of time, you may begin to see a pattern. 

A headache may be relieved by resting with your eyes closed and head supported. Relaxation techniques can help. A massage or heat applied to the back of the upper neck can be effective in relieving tension headaches. 

Try acetaminophen, aspirin, or ibuprofen for tension headaches. Do NOT give aspirin to children because of the risk of Reye syndrome. 

Migraine headaches may respond to nonsteroidal anti-inflammatory drugs (NSAIDs), or migraine medications that contain a combination of drugs. 

If over-the-counter remedies do not control your pain, talk to your doctor about possible prescription medications. 

Prescription medications used for migraine headaches include ergotamine, dihydroergotamine, ergotamine with caffeine (Cafergot), isometheptene (Midrin), and triptans like sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax), almotriptan (Axert), and zolmitriptan (Zomig). Sometimes medications to relieve nausea and vomiting are helpful for other migraine symptoms. 

If you get headaches often, your doctor may prescribe medication to prevent headaches before they occur. It is important to take these medicines every day as prescribed, even when you are not having a headache. 

People who take pain medications regularly for 3 or more days a week may develop medication overuse, or rebound, headaches. All types of pain pills (including over-the-counter drugs) can cause rebound headaches. If you think this may be a problem for you, talk to your health care provider. 

When to Contact a Medical Professional 
Take the following symptoms seriously. If you cannot see your health care provider immediately, go to the emergency room or call 911 if:

  • This is the first headache you have ever had in your life and it interferes with your daily activities
  • Your headache comes on suddenly and is explosive or violent
  • You would describe your headache as "your worst ever" even if you are prone to headaches
  • Your headache is associated with slurred speech, change in vision, problems moving your arms or legs, loss of balance, confusion, or memory loss
  • Your headache gets progressively worse over a 24-hour period
  • Your headache is accompanied by fever, stiff neck, nausea, and vomiting
  • Your headache occurs with a head injury
  • Your headache is severe and localized to one eye with redness in that eye
  • You are over age 50 and your headaches just began, especially with impaired vision and pain while chewing
  • You have cancer and develop a new headache

See your provider soon if:

  • Your headaches wake you up from sleep
  • A headache lasts more than a few days
  • Headaches are worse in the morning
  • You have a history of headaches but they have changed in pattern or intensity
  • You have headaches frequently, and there is no known cause

What to Expect at Your Office Visit 
Your health care provider will obtain your medical history and will perform an examination of your head, eyes, ears, nose, throat, neck, and nervous system. 

The diagnosis is usually based on your history of symptoms. A "headache diary" may be helpful for recording information about headaches over a period of time. Your doctor may ask questions such as the following: 

  • Is the headache located in the forehead, around the eyes, in the back of the head, near the temples, behind the eyeball, or all over? 
  • Is the headache on one side only? 
  • Is this a new type of headache for you? 
  • Would you describe the headache as throbbing? 
  • Is there a pressure or band-like sensation? 
  • When does the headache occur? How long have you had headaches? How long does each headache last? 
  • Does the headache awaken you from sleep? Are the headaches worse during the day and better at night? 
  • Did other symptoms begin shortly after the headaches began? Do headaches occur repeatedly? 
  • Does the headache reach maximum intensity over 1 to 2 hours? 
  • Are the headaches worse when you are lying down? Standing up? 
  • Are the headaches worse when you cough or strain? 
  • Do they occur at a specific time related to your menstrual period? 
  • What home treatment have you tried? How effective was it?

Diagnostic tests that may be performed include the following:

  • Head CT scan
  • Head MRI
  • Sinus x-rays
  • Temporal artery biopsy
  • Lumbar puncture

If a migraine is diagnosed, medications that contain ergot may be prescribed. Temporal arteritis must be treated with steroids to help prevent blindness. Other disorders are treated as is appropriate. 

Prevention 
The following healthy habits can lessen stress and reduce your chance of getting headaches:

  • Getting adequate sleep
  • Eating a healthy diet
  • Exercising regularly
  • Stretching your neck and upper body, especially if your work involves typing or using a computer
  • Learning proper posture
  • Quitting smoking
  • Learning to relax using meditation, deep breathing, yoga, or other techniques
  • Wearing proper eyeglasses, if needed

Cluster

A cluster headache is one-sided head pain that may involve tearing of the eyes and a stuffy nose. Attacks occur regularly for 1 week to 1 year, separated by long pain-free periods that last at least 1 month, possibly longer. 

Causes 
Cluster headaches are a fairly common form of chronic, repeated headaches. They are more common in men than women. The headaches can occur at any age but are most common in adolescence and middle age. The tend to run in families. 

Scientists do not know exactly what causes cluster headaches, but they appear to be related to the body's sudden release of histamine or serotonin. 

The following may trigger cluster attacks:

  • Alcohol and cigarette smoking
  • High altitudes (trekking, air travel)
  • Bright light (including sunlight)
  • Exertion
  • Heat (hot weather, hot baths)
  • Foods high in nitrites (such as bacon and preserved meats)
  • Certain medications
  • Cocaine

Symptoms 
A cluster headache begins as a severe, sudden headache. The headache most commonly strikes 2 to 3 hours after falling asleep, usually during the dreaming (rapid eye movement, or REM) phase. However, the headache may occur while you are awake. The headache tends to occur at the same time of day. 

The pain occurs on one side of the head. It may be described as:

  • Burning
  • Sharp
  • Steady

The pain may occur in, behind, and around one eye. It may:

  • Involve one side of the face from neck to temples
  • Quickly gets worse, peaking within 5 to 10 minutes
  • The strongest pain may last 30 minutes to 2 hours

The eye and nose on the same side of the head pain may also be affected. Symptoms can include:

  • Swelling under or around the eye (may affect both eyes)
  • Excessive tearing
  • Red eye
  • Rhinorrhea (runny nose) or one-sided stuffy nose (same side as the head pain)
  • Red, flushed face

Cluster headaches may occur daily for months, alternating with periods without headaches (episodic), or they can recur for a year or more without stopping (chronic). 

Exams and Tests 
Your health care provider can diagnosis this type of headache by performing a physical exam and asking questions about your symptoms and medical history. 

If a physical exam is done during an attack, the exam will usually reveal Horner syndrome (one-sided eyelid drooping or a small pupil). These symptoms will not be present at other times. No other neurological changes will be seen. 

Tests, such as an MRI of the head, may be needed to rule out other causes for the headaches. 

Treatment 
Treatment does not cure cluster headaches. The goal of treatment is to relieve symptoms. The headaches may go away on their own, or you may need treatment to prevent them. 

Smoking, alcohol use, specific foods, and other factors that seem to trigger cluster headaches should be avoided. A headache diary can help you identify your headache triggers. When you get a headache, write down the day and time the pain began. The diary should include notes about what you ate and drank in the last 24 hours, how much you slept and when, and what was going on in your life immediately before the pain started. For example, were you under any unusual stress? Also include information about how long the headache lasted, and what made it stop. 

Treatment for cluster headaches involves:

  • Methods to treat the pain when it happens
  • Medicines to prevent the headaches

Your doctor may recommend the following treatments for when the headaches occurs:

  • Triptans, such as sumatriptan (Imitrex)
  • Several weeks of anti-inflammatory (steroid) medicines such as prednisone -- starting with a high dose, then gradually decreased
  • Breathing in 100% (pure) oxygen, often relieves cluster headache for some people, particularly for frequent cluster headaches that occur at night
  • Injections of the drug known as dihydroergotamine (DHE), which can stop cluster attacks within 5 minute (Warning: this drug can be dangerous if taken with sumatriptan)

A combination of medicines may be needed to control headache symptoms. Because each person responds differently to medicine, your doctor may have you try several medications before deciding which works best for you. 

Painkillers do not usually relieve the pain from cluster headaches. Generally, they take too long to work. 

The following medications may also be used to treat or prevent headache symptoms:

  • Antiseizure medications such as topiramate and valproic acid
  • Indomethacin or naproxen
  • Lithium carbonate
  • Calcium channel blockers such as verapamil
  • Propranolol
  • Amitriptyline
  • Cyproheptadine

In rare cases, surgery on certain nerve cells near the brain may be recommended if medications do not work. 

Outlook (Prognosis) 
Cluster headaches are not life-threatening and usually cause no permanent structural changes. However, they are chronic and often painful enough to interfere with work or lifestyle. Occasionally, the pain may be so severe that some people may consider self harm. 

Side effects of medications or surgery may be severe. 

Possible Complications

  • Headaches that interfere with daily activities
  • Horner syndrome
  • Side effects of medications
  • Complications due to surgery to treat the headaches, including:
  • Permanent muscle weakness in the face or head
  • Decreased sensation in parts of the face or head

When to Contact a Medical Professional 
Call for an appointment with your health care provider if cluster headaches do not respond to treatment, if headaches disturb sleep, if they happen whenever you are active, or are accompanied by other symptoms. 

Emergency symptoms include drowsiness, vision changes, changes in movement or sensation, seizures, changes in alertness, and nausea or vomiting. 

Prevention 
If prone to cluster headache, stop smoking. Alcohol use and any foods that are associated with cluster headache may need to be avoided. Medications may prevent cluster headaches in some cases. 

Migraine

A migraine is a common type of headache that may occur with symptoms such as nausea, vomiting, or sensitivity to light. In many people, a throbbing pain is felt only on one side of the head. 

Some people who get migraines have warning symptoms, called an aura, before the actual headache begins. An aura is a group of symptoms, usually vision disturbances, that serve as a warning sign that a bad headache is coming. Most people, however, do not have such warning signs. 

Causes 
A lot of people get migraines -- about 11 out of 100. The headaches tend to first appear between the ages of 10 and 46. Occasionally, migraines may occur later in life in a person with no history of such headaches. Migraines occur more often in women than men, and may run in families. Women may have fewer migraines when they are pregnant. Most women with such headaches have fewer attacks during the last two trimesters of pregnancy. 

A migraine is caused by abnormal brain activity, which is triggered by stress, certain foods, environmental factors, or something else. However, the exact chain of events remains unclear. 

Scientists used to believe that migraines were due to changes in blood vessels within the brain. Today, most medical experts believe the attack actually begins in the brain itself, where it involves various nerve pathways and chemicals. The changes affect blood flow in the brain and surrounding tissues. 

Migraine attacks may be triggered by:

  • Alcohol
  • Allergic reactions
  • Bright lights
  • Certain odors or perfumes
  • Changes in hormone levels (which can occur during a woman's menstrual cycle or with the use of birth control pills)
  • Changes in sleep patterns
  • Exercise
  • Loud noises
  • Missed meals
  • Physical or emotional stress
  • Smoking or exposure to smoke

Certain foods and preservatives in foods may trigger migraines in some people. Food-related triggers may include:

  • Any processed, fermented, pickled, or marinated foods
  • Baked goods
  • Chocolate
  • Dairy products
  • Foods containing monosodium glutamate (MSG)
  • Foods containing tyramine, which includes red wine, aged cheese, smoked fish, chicken livers, figs, and certain beans
  • Fruits (avocado, banana, citrus fruit)
  • Meats containing nitrates (bacon, hot dogs, salami, cured meats)
  • Nuts
  • Onions
  • Peanut butter

This list may not include all triggers. 

True migraine headaches are not a result of a brain tumor or other serious medical problem. However, only an experienced health care provider can determine whether your symptoms are due to a migraine or another condition. 

Symptoms 
Vision disturbances, or aura, are considered a "warning sign" that a migraine is coming. The aura occurs in both eyes and may involve any or all of the following:

  • A temporary blind spot
  • Blurred vision
  • Eye pain
  • Seeing stars or zigzag lines
  • Tunnel vision

Not every person with migraines has an aura. Those who do usually develop one about 10 - 15 minutes before the headache. However, it may occur just a few minutes to 24 hours beforehand. A headache may not always follow an aura. 

Migraine headaches can be dull or severe. The pain may be felt behind the eye or in the back of the head and neck. For many patients, the headaches start on the same side each time. The headaches usually:

  • Feel throbbing, pounding, or pulsating
  • Are worse on one side of the head
  • Start as a dull ache and get worse within minutes to hours
  • Last 6 to 48 hours

Other symptoms that may occur with the headache include:

  • Chills
  • Increased urination
  • Fatigue
  • Loss of appetite
  • Nausea and vomiting
  • Numbness, tingling, or weakness
  • Problems concentrating, trouble finding words
  • Sensitivity to light or sound
  • Sweating

Symptoms may linger even after the migraine has gone away. Patients with migraine sometimes call this a migraine "hangover." Symptoms can include:

  • Feeling mentally dull, like your thinking is not clear or sharp
  • Increased need for sleep
  • Neck pain

Exams and Tests 
Your doctor can diagnose this type of headache by asking questions about your symptoms and family history of migraines. A complete physical exam will be done to determine if your headaches are due to muscle tension, sinus problems, or a serious brain disorder. 

There is no specific test to prove that your headache is actually a migraine. However, your doctor may order a brain MRI or CT scan if you have never had one before. 

If you have a migraine with unusual symptoms such as weakness, memory problems, or loss of alertness, an EEG may be needed to rule out seizures. A lumbar puncture (spinal tap) might be done. 

Treatment 
There is no specific cure for migraine headaches. The goal is to prevent symptoms by avoiding or changing your triggers. 

A good way to identify triggers is to keep a headache diary. Write down:

  • When your headaches occur
  • How severe they are
  • What you've eaten
  • How much sleep you had
  • Other symptoms
  • Other possible factors (women should note where they are in their menstrual cycle)

For example, the diary may reveal that your headaches tend to occur more often on days when you wake up earlier than usual. Changing your sleep schedule may result in fewer migraine attacks. 

When you do get migraine symptoms, try to treat them right away. The headache may be less severe. When migraine symptoms begin:

  • Drink water to avoid dehydration, especially if you have vomited
  • Rest in a quiet, darkened room
  • Place a cool cloth on your head

Many different medications are available for people with migraines. Medicines are used to:

  • Reduce the number of attacks
  • Stop the migraine once early symptoms occur
  • Treat the pain and other symptoms

REDUCING ATTACKS 

If you have frequent migraines, your doctor may prescribe medicine to reduce the number of attacks. Such medicine needs to be taken every day in order to be effective. Such medications may include:

  • Antidepressants such as amitriptyline
  • Blood pressure medicines such as beta blockers (propanolol) or calcium channel blockers (verapamil)
  • Seizure medication such as valproic acid, gabapentin and topiramate
  • Serotonin reuptake inhibitors (SSRIs) such as venlafaxine
  • Selective norepinephrine uptake inhibitor (SNRIs) such as duloxetine

STOPPING AN ATTACK 

Other medicines are taken at the first sign of a migraine attack. Over-the-counter pain medications such as acetaminophen, ibuprofen, or aspirin are often helpful, especially when your migraine is mild. If these don't help, ask your doctor about prescription medications. (Be aware, however, that overuse or misuse of such pain medications may result in rebound headaches. Chronic rebound headaches typically occur in people who take pain medications more than 3 days a week on an ongoing basis.) 

Your doctor can select from several different types of medications, including:

  • Triptans -- the most frequently prescribed medicines for stopping migraine attacks -- such as almotriptan (Axert), frovatriptan (Frova), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig)
  • Ergots such as dihydroergotamine or ergotamine with caffeine (Cafergot)
  • Isometheptene (Midrin)

These medications come in different forms. Patients who have nausea and vomiting with their migraines may be prescribed a nasal spray, suppository, or injection instead of pills. 

Some migraine medicines narrow your blood vessels and should not be used if you are at risk for heart attacks or have heart disease, unless otherwise instructed by your health care provider. Ergots should not be taken if you are pregnant or planning to become pregnant, because they can cause serious side effects to an unborn baby. 

TREATING SYMPTOMS 

Other medications are primarily given to treat the symptoms of migraine. Used alone or in combinations, these drugs can reduce your pain, nausea, or emotional distress. Medications in this group include:

  • Nausea medicines such as prochlorperazine
  • Over-the-counter pain relievers such as acetaminophen (Tylenol)
  • Sedatives such as butalbital
  • Narcotic pain relievers such as meperidine
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen

If you wish to consider an alternative, feverfew is a popular herb for migraines. Several studies, but not all, support using feverfew for treating migraines. If you are interested in trying feverfew, make sure your doctor approves. Also, know that herbal remedies sold in drugstores and health food stores are not regulated. Work with a trained herbalist when selecting herbs. 

Support Groups 
American Council for Headache Education
The National Migraine Association
National Headache Foundation

Outlook (Prognosis) 
Every person responds differently to treatment. Some people have rare headaches that require little to no treatment. Others require the use of several medications or even occasional hospitalization. 

Possible Complications 
Migraine headache is a risk factor for stroke in both men and women. 

Migraine headaches generally represent no significant threat to your overall health. However, they can be a long-term (chronic) problem and may interfere with your day-to-day life. 

When to Contact a Medical Professional 
Call 911 if:

  • You are experiencing "the worst headache of your life"
  • You have speech, vision, or movement problems or loss of balance, especially if you have not had these symptoms with a migraine before
  • Your headaches are more severe when lying down
  • The headache starts very suddenly

Also, call your doctor if:

  • Your headache patterns or pain change
  • Treatments that once worked are no longer helpful
  • You have side effects from medication, including irregular heartbeat, pale or blue skin, extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain, cramps, dry mouth, or extreme thirst
  • You are pregnant or could become pregnant -- some medications should not be taken when pregnant

Prevention 
Understanding your headache triggers can help you avoid foods and situations that cause your migraines. Keep a headache diary to help identify the source or trigger of your symptoms. Then modify your environment or habits to avoid future headaches. 

Other tips for preventing migraines include:

  • Avoid smoking
  • Avoid alcohol
  • Avoid artificial sweeteners and other known food-related triggers
  • Get regular exercise
  • Get plenty of sleep each night

Learn to relax and reduce stress -- some patients have found that biofeedback and self-hypnosis helps reduce the number of migraine attacks

Mixed Tension

Mixed tension migraine is a headache with features of both tension and migraine headaches. 

Causes 
Migraine headaches affect millions of people. Tension headaches are even more common, affecting about 40% of the population. People with mixed tension migraine have features of both types of headaches. It is difficult to differentiate which symptoms are due to which type of headache. Women have mixed tension migraines more often than men. 

Common triggers for these headaches are hormonal changes, dietary factors, environmental factors, stimulation, and stress. Examples include:

  • Alcohol
  • Bright light
  • Food and food additives
  • Missed or delayed meals
  • Menstruation
  • Odors
  • Too much or too little sleep
  • Use and withdrawal of certain drugs or medications

Symptoms

  • Headache on one or both sides
  • Throbbing pain
  • May feel dull, tight, or like a band around the head
  • Pain varies from mild to severe
  • May get worse with activity
  • May last 4 - 72 hours (in some people, the headaches may occur every day)
  • Nausea or vomiting
  • Sensitivity to light or sound
  • Irritability
  • Depression
  • Sluggishness
  • Numbness, tingling, weakness
  • Neck pain

Exams and Tests 
Your doctor will perform a physical exam, including a detailed examination of your nervous system, and ask you about your symptoms and family history. 

Tests that may be done include:

  • CT or MRI of the head and neck
  • Blood work
  • Lumbar puncture (spinal tap)

Treatment 
Certain things may cause your headaches. For example, some people get headaches after drinking alcohol or eating certain foods. These are called triggers. You should identify your specific triggers and avoid them as much as possible. 

A headache diary can help you identify your headache triggers. When you get a headache, write down the day and time the pain began. The diary should include notes about what you ate and drank in the last 24 hours, how much you slept and when, and what was going on in your life immediately before the pain started. For example, were you under any unusual stress? Also include information about how long the headache lasted, and what made it stop. 

Hot or cold showers or baths may relieve a headache for some people. It is important to follow a healthy lifestyle, get plenty of sleep, and to avoid stress as much as possible. 

Over-the-counter medicines such as ibuprofen and acetaminophen may help. If your headaches are severe, your doctor may prescribe other medicines to relieve your pain and prevent further attacks. 

Outlook (Prognosis) 
Avoiding triggers and taking the appropriate medicine can help manage headache symptoms in many people. 

Possible Complications 
Pain medications only relieve headache symptoms for a short period of time. After a while, they do not work as well or the help they provide does not last as long. Regular, overuse of pain medications can lead to rebound headaches. Typically this occurs in people who take pain medications 3 or more times a week on a regular basis. 

It's important to see a doctor if you have chronic headaches. In some cases, the headache may be a symptom of a more serious disorder. 

When to Contact a Medical Professional 
It is important to have a full medical and neurological exam if you suddenly have regular or severe headaches. 

Call 911 or your local emergency number if:

  • You are experiencing "the worst headache of your life"
  • You have speech, vision, or movement problems or loss of balance, especially if you have not had these symptoms with a headache before
  • Your headaches are more severe when lying down
  • The headache starts very suddenly

Also, call your doctor if:

  • Your headache patterns or pain change
  • Treatments that once worked are no longer helpful
  • You have side effects from medication, including irregular heartbeat, pale or blue skin, extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain, cramps, dry mouth, or extreme thirst
  • You are pregnant or could become pregnant -- some medications should not be taken when pregnant

Prevention 
Tips for preventing headaches:

  • Avoid triggers.
  • Get enough sleep.
  • Eat a proper diet.
  • Exercise regularly.
  • Medicine may be needed to prevent headaches.

Sinus

Sinus headaches cause a dull, deep, throbbing pain in the front of your head and face. They are caused by an inflammation in your sinuses (air-filled cavities around your nose, eyes, and cheeks). Bending down or leaning over generally makes the pain worse, as does cold and damp weather. Sinus headaches often begin as soon as you get up in the morning, and may be better by afternoon. Sinus headaches can be difficult to diagnose, however, because symptoms are similar to tension headaches and migraines. 

Signs and Symptoms
Sinus headaches generally have these symptoms:

  • Pressure like pain in one specific area of your face or head (for example, behind your eyes)
  • Face is tender to the touch
  • Pain is worse with sudden movements of the head and bending forward
  • Worse pain in the morning (because mucus has been collecting and draining all night)
  • Sudden temperature changes, like going out into the cold from a warm room, worsen the pain
  • Headache often starts when you have a bad cold or just after

Other symptoms may be related to sinus inflammation (sinusitis):

  • Postnasal drip with sore throat (pharyngitis)
  • Yellow or green discharge from your nose
  • Red and swollen nasal passages (nasal congestion)
  • Mild to moderate fever
  • General sense of not feeling well (malaise)
  • Fatigue

Causes
Sinus headaches can be caused by sinus congestion and inflammation (called sinusitis). Sinusitis, in turn, is caused by either a respiratory infection (such as a cold or flu) or allergies (like hay fever). Healthy sinuses allow mucus to drain and air to circulate throughout the nasal passages. When sinuses become inflamed, these areas get blocked and mucus cannot drain. When sinuses become blocked, they provide a place for bacteria, viruses, and fungus to live and grow rapidly. Although a cold is most often the culprit, sinusitis can be caused by anything that prevents the sinuses from draining. 

Risk Factors

  • History of allergies (especially hay fever) or asthma
  • Nasal polyps (swellings in the nasal passage), nasal bone spurs, nasal or facial tumor, deviated septum, or cleft palate
  • Climbing or flying to high altitudes
  • Frequent swimming and/or diving

Diagnosis
Your doctor will ask questions in order to distinguish sinus headaches from migraines or tension headaches. If you have had a recent cold, allergy flare up, and/or symptoms of sinusitis, it will help your doctor make a definite diagnosis. 

Your doctor will look in your nose to check for congestion and nasal discharge. He or she will also press on areas of your face to check for tenderness. Transillumination (shining a light through the sinuses) is another simple method that your doctor may use to look for sinus inflammation; if the light does not shine through, your sinuses may be congested. 

If your doctor suspects chronic sinusitis, he or she may order imaging tests, including an x-ray, computed tomography (CT) scan, or magnetic resonance imaging (MRI). If your doctor suspects allergies may be causing your sinusitis, he or she may suggest an allergy test. Sometimes, a referral to a specialist – known as an ear, nose and throat (ENT) doctor or an otolaryngologist – is necessary. This specialist may perform a nasal endoscopy using a fiber optic scope to look at your sinuses. 

Treatment Approach
The best way to avoid or get rid of a sinus headache is to treat the underlying sinus inflammation. Your doctor may prescribe antibiotics or corticosteroids. Lifestyle changes, such as using a humidifier or irrigating your nasal passages with salt water, may also help. Several dietary supplements and herbs may help prevent colds and flu or shorten their duration, or work together with antibiotics to treat your infection and support your immune system. 

Lifestyle
Doing the following things can help reduce congestion in your sinuses:

  • Using a humidifier
  • Using a saline nasal spray
  • Inhaling steam 2 - 4 times per day (for example, sitting in the bathroom with the shower running)
  • Quickly treating allergic and asthma attacks

Other techniques that might help include:

  • Stretches for the head and neck
  • Relaxation techniques (see Mind/Body Medicine section)

Medications
Antibiotics — Your doctor may prescribe antibiotics if he or she suspects you have a bacterial infection. To treat acute sinusitis, you may take from 10 - 14 days of antibiotics. Treating chronic sinusitis may take longer, usually 3 - 4 weeks. 

Nasal corticosteroids — These prescription sprays reduce inflammation of the nose and help relieve sneezing, itching, and runny nose. They are most effective at reducing symptoms, although it can take from a few days to a week after you start using them to see improvement. 
 

  • Beclomethasone (Beconase) 
  • Fluticasone (Flonase) 
  • Mometasone (Nasonex) 
  • Triacinolone (Nasacort)
  • Antihistamines — Antihistamines are available in both oral and nasal spray forms, and as prescription drugs and over-the-counter remedies, to treat allergies. Over the counter antihistamines are short acting and can relieve mild to moderate symptoms. All work by blocking the release of histamine in your body. 
  • Over the counter antihistamines: Include diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton), clemastine (Tavist). These older antihistamines can cause sleepiness. Loratadine (Claritin), a newer antihistamine, does not cause drowsiness. 
  • Prescription antihistamines: These medications are longer-acting than over the counter antihistamines and are usually taken once a day. They include fexofenadine (Allegra) and cetrizine (Zyrtec).
  • Decongestants — Many over the counter and prescription decongestants are available in tablet or nasal spray form. They are often used with antihistamines. 
  • Oral and nasal decongestants: Include Sudafed, Actifed, Afrin, Neo-Synephrin. Some decongestants may contain pseudoephedrine, which can raise blood pressure. People with high blood pressure or enlarged prostate should not take drugs containing pseudoephedrine. Nasal decongestants can cause "rebound congestion," where the nasal passages swell. Avoid using nasal decongestants for more than 3 days in a row, unless specifically instructed by your doctor, and do not use them if you have emphysema or chronic bronchitis.
  • Triptans -- The majority of sinus headaches satisfy the critria of migraines. In one study, 82% of patients with sinus headaches had a significant response to triptans, a medication commonly used for migraines. 

Surgery and Other Procedures
For chronic sinusitis that doesn’t respond to medication, your doctor may recommend endoscopic sinus surgery, which may be done to remove polyps or bone spurs. Enlarging the sinus opening is also sometimes recommended. A newer procedure called balloon rhinoplasty involves inserting a balloon inside the sinus cavity and then inflating it. 

Surgical procedures for sinuses are performed by an ENT specialist. 

Nutrition and Dietary Supplements
Several supplements may help prevent or treat sinus headaches, either by reducing sinus inflammation or by helping to ward off colds. (See Sinusitis for more details.) Because supplements may have side effects or interact with medications, you should take them only under the supervision of a knowledgeable health care provider. 

Warnings and Precautions
You should seek emergency medical attention if you experience the following:

  • Sudden and severe headache that persists or increases in intensity over 24 hours
  • A sudden, severe headache that you describe as "your worst ever," even if you are prone to headaches
  • Chronic or severe headaches that begin after age 50
  • Headaches accompanied by memory loss, confusion, loss of balance, change in speech or vision, or loss of strength in or numbness/tingling in any one of your limbs
  • Headaches accompanied by fever, stiff neck, nausea and vomiting (may indicate meningitis)
  • Severe headache localized to one eye, accompanied by redness of the eye (may indicate acute glaucoma)

Tension

A tension headache is pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas. 

Causes 
Tension headaches are one of the most common forms of headaches. They may occur at any age, but are most common in adults and adolescents. 

If a headache occurs two or more times a week for several months or longer, the condition is considered chronic. Chronic daily headaches can result from the under- or over-treatment of a primary headache. For example, patients who take pain medication more than 3 days a week on an regular basis can develop rebound headaches. 

Tension headaches can occur when the patient also has a migraine. 

Tension headaches occur when neck and scalp muscles become tense, or contract. The muscle contractions can be a response to stress, depression, a head injury, or anxiety. 

Any activity that causes the head to be held in one position for a long time without moving can cause a headache. Such activities include typing or other computer work, fine work with the hands, and using a microscope. Sleeping in a cold room or sleeping with the neck in an abnormal position may also trigger a tension headache. 

Other triggers of tension headaches include:

  • Alcohol use
  • Caffeine (too much or withdrawal)
  • Colds and the flu
  • Dental problems such as jaw clenching or teeth grinding
  • Eye strain
  • Excessive smoking
  • Fatigue
  • Nasal congestion
  • Overexertion
  • Sinus infection
  • Tension headaches are not associated with structural changes in the brain.

Symptoms 
The headache pain may be described as:

  • Dull, pressure-like (not throbbing)
  • A tight band or vise on the head
  • All over (not just in one point or one side)
  • Worse in the scalp, temples, or back of the neck, and possibly in the shoulders
  • The pain may occur as an insolated event, constantly, or daily. Pain may last for 30 minutes to 7 days. It may be triggered by or get worse with stress, fatigue, noise, or glare.

There may be difficulty sleeping. Tension headaches usually do not cause nausea or vomiting.
People with tension headaches tend to try relieve pain by massaging their scalp, temples, or the bottom of the neck. 

Exams and Tests 
A headache that is mild to moderate, not accompanied by other symptoms, and responds to home treatment within a few hours may not need further examination or testing, especially if it has occurred in the past. A tension headache reveals no abnormal findings on a neurological exam. However, tender points (trigger points) in the muscles are often seen in the neck and shoulder areas. 

The health care provider should be consulted -- to rule out other disorders that can cause headache -- if the headache is severe, persistent (does not go away), or if other symptoms are present with the headache. 

Headaches that disturb sleep, occur whenever you are active, or that are recurrent or chronic may require examination and treatment by a health care provider. 

Treatment 
Understanding your headache triggers can help you avoid situations that cause your headaches. A headache diary can help you identify your headache triggers. When you get a headache, write down the day and time the pain began. The diary should include notes about what you ate and drank in the last 24 hours, how much you slept and when, and what was going on in your life immediately before the pain started. For example, were you under any unusual stress? Also include information about how long the headache lasted, and what made it stop. 

Hot or cold showers or baths may relieve a headache for some people. You may need to make lifestyle changes if you have chronic tension headaches. This may include changing your sleep habits (usually to get more sleep), increasing exercise, and stretching the neck and back muscles. In some situations, you may need to change your job or recreational habits. 

Over-the-counter painkillers such as aspirin, ibuprofen, or acetaminophen may relieve pain if relaxation techniques do not work. If you are planning to take part in an activity that you know will trigger a headache, taking one of these painkillers beforehand may be helpful. 

Narcotic pain relievers are sometimes prescribed. Remember that pain medications only relieve headache symptoms for a short period of time. After a while, they do not work as well or the help they provide does not last as long. Regular, overuse of pain medications can lead to rebound headaches. 

Other prescription treatments may include:

  • Muscle relaxants such as tizanidine
  • Selective serotonin-reuptake inhibitors (SSRIs) such as paroxetine (Paxil) or citalopram (Celexa) taken daily to help prevent or decrease the number of headaches
  • Tricyclic antidepressants such as amitriptyline, nortriptyline, or doxepin taken daily to help prevent or decrease the number of headaches
  • Combining drug treatment with relaxation or stress-management training, biofeedback, cognitive behavioral therapy, or acupuncture may provide better relief for chronic headaches.

Botox (botulinum toxin) is becoming popular as a treatment for chronic daily headaches, including tension headaches. However, it is currently not approved for such use. 

Outlook (Prognosis) 
Tension headaches usually respond well to treatment without residual effects. 

Although they are not medically dangerous, chronic tension headaches can have a negative impact on the quality of life and work productivity. 

Possible Complications 
Rebound headaches -- headaches that keep coming back -- may occur from overuse of painkillers. 

It's important to see a doctor if you have chronic headaches. In some cases, the headache may be a symptom of a more serious disorder. 

When to Contact a Medical Professional 
Call 911 if:

  • You are experiencing "the worst headache of your life"
  • You have speech, vision, or movement problems or loss of balance, especially if you have not had these symptoms with a headache before
  • Your headaches are more severe when lying down
  • The headache starts very suddenly

Also, call your doctor if:

  • Your headache patterns or pain change
  • Treatments that once worked are no longer helpful
  • You have side effects from medication, including irregular heartbeat, pale or blue skin, extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain, cramps, dry mouth, or extreme thirst
  • You are pregnant or could become pregnant -- some medications should not be taken when pregnant

Prevention 
Learn and practice stress management. Some people find relaxation exercises or meditation helpful. Biofeedback may improve relaxation exercises and may be helpful for chronic tension headache. 

Tips to prevent tension headaches:

  • Keep warm if the headache is associated with cold.
  • Use a different pillow or change sleeping positions.
  • Practice good posture when reading, working, or doing other activities.
  • Exercise the neck and shoulders frequently when typing, working on computers, or doing other close work.
  • Get plenty of sleep and rest.
  • Massaging sore muscles may also help.

What to ask your doctor

Consider asking your provider some or all of these questions during your visit.

  • How can I tell if the headache I am having is dangerous?
  • What are the symptoms of a tension headache? A migraine headache? A cluster headache?
  • What medical problems can cause headaches? What tests do I need?
  • What changes in my lifestyle may help my headaches?
  • Are there foods that make my headaches worse that I should stay away from?
  • Are there medicines that may be causing my headaches?
  • Will alcohol or cigarette smoking make my headaches worse?
  • Will exercise help my headaches?
  • What are the pain medicines that can be used for headaches?
  • Will taking too many pain medicines make my headaches worse?
  • What are the side effects of these medicines?
  • Will any of these medicines make me sleepy or confused?
  • What should I do when I feel a headache beginning?
  • Are there medicines I can take that will stop the headache?
  • What can I do when I have headaches at work?
  • Are there medicines that I can take that will make my headaches come less often?
  • What can I do about nausea or vomiting with my headaches?
  • Are there any herbs or supplements that I can take that will help? How do I know if they are safe?

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