Headache

A headache refers to continuous or persisting pain involving any area of the head or neck region. The symptoms that accompany a headache are usually the deciding factors in understanding the type of headache by the doctor. Headaches are generally diagnosed on the basis of symptoms and clinical examination. Imaging tests are required if a secondary cause of a headache is suspected.

Headaches are one of the most common health complaints and include a wide array of neurologic disorders. It is estimated that the lifelong prevalence of a headache is 96%, with a tendency to affect women more than men. Currently, the global active prevalence of a tension-type headache is approximately 40%, migraine is 10%, and cluster headaches is 1%. Nowadays, experts insist that the first step to ensuring successful treatment, perhaps the most important, is establishing whether the headache type is primary or secondary. Therefore having an understanding of the types of headaches along with some warning signs could go a long way in ensuring that headaches are managed effectively.

Primary Headaches

Primary headaches are those that occur as a stand-alone illness. These headaches are caused by overactivity or problems in those structures of the brain that are pain sensitive. These structures include nerves, blood vessels and muscles of the head and the neck. Primary headaches could also be a result of changes in the chemical activity within the brain. However, what sets off the process of a primary headache remains uncertain. It is generally thought that a series of events that affects blood vessels and nerves both within and outside the head triggers pain signals via chemical messengers known as neurotransmitters which are sent to the brain. However, some people also carry genes that makes them more prone to develop such headaches. Primary headaches include: 

• Migraine
• Tension-type headache
• Cluster headache

Secondary Headaches

Secondary headaches are symptoms resulting from an underlying health condition which triggers the pain sensitive areas of the brain. These headaches are serious in nature and need to be detected and treated as an emergency. Some examples of secondary headaches include:

• Injury to the head and/or neck region
• Cranial or cervical vascular diseases
• Nonvascular intracranial disorders 
• Use of a substance or its withdrawal
• Infections
• Disorders of homeostasis
• Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structures
• Psychiatric disorders

Different types of headaches present differently, having characteristic patterns. By identifying the pattern of a headache, doctors narrow down their diagnosis about the possible type your headache as well as the need for further investigations and treatment plan. 

Primary headache
Some of the common types of headaches and their presenting symptom patterns are as follows:

• Migraine
  Migraines are dominantly inherited, which is preceded by a fully reversible set of nervous system symptoms that are usually visual or sensory. The headaches typically develop gradually; recede – known as an ‘aura’; and are further characterized by varying degrees of recurrent headaches, sensitivity to light, disruption of sleep patterns, and depression.
   
• Tension-type Headache
  It is a very common variant of a headache, with a lifetime prevalence of almost 80%. It presents as a dull headache, usually involves both sides of the head, is mild to moderate in intensity, and is associated with pressure or pain. Striking associated features are usually absent and the headache can be infrequent, frequent, or chronic.
   
• Cluster Headache
  A cluster headache a is sudden onset headache involving middle and upper part of face and area around eyes. It can occur 1-8 times per day for weeks to months. In between these cluster periods of a headache, there may be periods of no headache symptoms. These headache free symptoms could last for months to years. It is usually abrupt in onset, has a burning quality to it, and typically lasts for 15 minutes to 3 hours. Occasionally, it may appear in the same 24-hour period, earning it the name ‘alarm clock headache’. It is characteristically associated with watery eyes, stuffy nose, and flushing.
   
• Sinus Headache
  The commonly seen symptoms include pain in the face or pressure and congestion of nose and sinuses along with a headache. A sinus headache is mostly experienced after a viral or bacterial sinus infection, associated with a thick, discolored nasal discharge, decreased sense of smell or no smell, pain-pressure in the face, and fever. It is known to resolve in a week’s time with antibiotics.
   
• Thunderclap Headache
  It is characterized by a pain that is very severe and intense. This headache may be sudden or gradual in onset. It can be either primary or secondary. Secondary causes usually include brain bleeds, a decrease of pressure in the brain and complications of hypertension.
   
• New Daily Persistent Headache
  It is a persistent headache that occurs daily, which is clearly remembered. The pain lacks characteristic features and is similar to a migraine or tension headaches. Diagnosis is established when the symptoms last for 3 months or more.
   
• Hemicrania Continua
  It is a type of chronic daily headache that presents as one-sided, moderately severe, and associated with watery eyes, redness, nasal stuffiness or a runny nose, and drooping eyelids similar to those of a cluster headache.

Secondary Headaches
When a headache does not fit into any of the primary categories, yet worsens, a red flag should be raised to detect an underlying condition. The secondary headaches as such do not have striking features.

Causes

As mentioned earlier, primary headaches are thought to be the result of aberrant neurotransmitter activity or of genetic origin.

Secondary headaches are usually indicative of a disease that can activate the pain-sensitive or cause the so-called ‘nociception’ in the nerves of the head. A large number of conditions can cause secondary headaches.

Risk Factors

Different types of headaches have their own risk factors. However, they can be grouped under a common category as follows:

• Irregular meals
• Disturbed sleep cycles
• Smoking
• Depression or anxiety
• Excessive alcohol usage
• Age
• Genetic factors
• Obesity
• Allergies
• Menstruation
• Low immunity

Since most of the headaches mentioned above except for a few are lifestyle related, here are a few handy tips to keep those headaches at bay:

Get adequate sleep
One of the major factors known to trigger tension-type and migraine headaches is the lack of good sleep or even the excess of it. Set a regular sleep routine by going to bed and waking up at almost the same time every day. Make sure you get a good 7-8 hours of sleep. Limit use of mobile phones and other gadgets one hour before bedtime. Avoid caffeinated drinks 1-2 hours before bedtime. If you face any difficulties in sleeping, such as insomnia (sleeplessness) or snoring, consult your doctor right away.

Avoid foods or drinks that you know trigger your headaches
Certain foods, such as nuts and beverages, such as caffeine, are notorious for causing migraines. However, additional ingredients in foods may also cause headaches on a regular basis. Keep a note of what triggers set you off the associated symptoms and stay clear of those items.

Keep a watch on what medicines and supplements you take
Many medications can unknowingly cause the common ‘withdrawal headaches’ because of the effect the drug has on the body. Speak to your doctor to gradually wean you off the medication; take note here that opioid-based painkillers, such as morphine, tend to cause such symptoms.

Have meals at regular intervals  
A migraine tends to affect people who are prone to skipping meals regularly. Have a balanced diet and make sure you have small frequent meals every 3-4 hours. Include whole grains, leafy greens, legumes, fish, poultry, fruits and good fats in your diet. Drink 1-2 liters of water daily. Increase your water intake during the summer months and while working outdoors. Stay away from fad diets and crash dieting which could trigger headaches.

Exercise regularly.
Include a 30-40 minute exercise routine in your daily schedule. Include activities like running, brisk walking, skipping, cycling or yoga. Else, you could enroll in a Zumba class to makes things fun as well as beneficial! Remember to ask your doctor about which exercise is okay for you.

Manage Stress 
It is a known fact that stress is the main trigger for several diseases, including headaches. Find healthy ways to beat everyday stress. Try deep breathing exercises, Tai Chi and meditation. Engage in a relaxing hobby like joining a book club or gardening. Show empathy by taking up volunteering work in your free time. Remember, the more care you take, the healthier you will be.

The diagnosis of any type of a headache is established by the doctor on the basis of clinical history, that is, to say, the diagnosis is mainly clinical unless the doctor suspects otherwise.
Providing the right history to your doctor, including how long ago the headaches started, the time of the day, frequency, the intensity of a headache, any associated symptoms, location, previous family history, any items that worsen the symptoms, the treatment you took, is crucial to make the correct diagnosis.
If the doctor suspects something more serious, he/she may order additional tests, such as X-rays or CT, MRI scans, to pinpoint the source of your headaches. In rare cases, a dye might be injected to look for blood-vessel related abnormalities before an imaging test like MRI is performed.

Consulting your doctor as early as possible to initiate treatment is the best way to tackle the problem. Based on your symptoms, your doctor may suggest the following treatments:

Educate yourself
One of the key factors contributing to a successful therapy is to educate oneself about the type of headache being experienced. Your doctor may provide a headache diary to record each episode in detail, along with the associated trigger factors, treatment taken for relief, and the notable further developments.

Manage Stress
As mentioned earlier, stress is one of the most common factors to trigger headaches in today’s scenario. Your doctor might suggest effective stress reduction techniques, such as yoga, meditation, deep breathing exercises, aromatherapy, music therapy, or even pet therapy.

Ask your doctor for medication
If the symptoms are too severe or persistent, your doctor might prescribe medications. Usually, these are grouped into three categories:

• Symptomatic medications
  These include simple over the counter drugs, such as paracetamol, aspirin, or ibuprofen. However, it must be remembered that overuse of drugs could be more harmful than beneficial; so, it is best to check with your doctor regarding the safety statistics.
   
• Abortive medications 
  As the name suggests, these drugs terminate the progression of headache symptoms as soon as the first sign develops. Drugs used in this category include injectable ergotamine and sumatriptan. However, these require a prescription.
   
• Preventive medications
  These are used to treat headaches if they are too severe or often. They include tricyclic antidepressants, such as amitriptyline; calcium channel blockers, such as amlodipine; antihistamines, such as pheniramine; and anticonvulsants, such as valproate. These must be prescribed by your doctor and should be taken with caution.

Try alternative therapies 
These are newer therapies and are usually used in conjunction with or to augment traditional therapy to improve results. They include:

• Acupuncture
• Deep brain stimulation
• Biofeedback
• Progressive muscle relaxation
• Counseling therapy

Lifestyle Modification

• Since headaches are very commonly associated with lifestyle and habits, the best way to prevent them is to incorporate small changes in your lifestyle, which are not limited to
• Regular sleep
• Regular meals
• Regular exercise
• Trigger avoidance
• Stress management
• Weight reduction (if applicable)
• Caffeine avoidance

Prognosis

The prognosis of headaches according to some experts may be related to the risk factors that cause them. 
Examples of these include:

• Depression/anxiety
• Medication overuse
• Poor quality sleep
• High stress
• Low headache management self-efficacy

Complications

Perhaps, of all the types of a primary headache, migraine poses the greatest risk for complication if left untreated. Some of the complications of a migraine include:

Status migrainosus
It is a persistent, unremitting attack occurring in cases of a migraine with or without aura, which occurs for periods greater than 72 hours, where the pain is described as debilitating.

Persistent aura without infarction
This is a condition in which the ‘aura’ that precedes a migraine, persists for more than a week’s time, but does not show changes in brain imaging scans.

Migrainous infarction
The migraine attack is preceded by an aura that lasts for an hour and shows evidence of damage in a relevant area on brain imaging scans.

Migraine-aura-triggered seizure
The migraine attack is preceded by an aura. This triggers an epileptic attack either during or after an hour of a migraine.