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Reviewed by the Faculty of Harvard Medical School

Frequently Asked Questions About Headaches

When should a headache sufferer see a health care professional ?

Almost everyone has occasional headaches, especially when they are sick, tired or otherwise under stress. Most headaches go away on their own or are easily treated with over-the-counter drugs. It is rarely necessary to see a health care professional for these types of headaches.

However, you should contact your health care professional if you have:

  • Very frequent headaches
  • Headaches that are not relieved by over-the-counter drugs
  • Headaches that interfere with daily activities, such as work, recreation or family time
  • Headaches with worrisome "red flag" symptoms

If you see a health care professional, he or she should be able to diagnose your particular type of headache, decide whether further evaluation is needed, and make recommendations about treatment. Occasionally, your primary care physician may decide that you need to see a neurologist (a doctor who specializes in problems of the brain and nervous system) or another type of headache specialist.

Are computed tomography (CT) and magnetic resonance imaging (MRI) scans necessary to diagnose headaches?

Many people worry that their headaches are caused by a serious underlying medical problem, such as a tumor or aneurysm. Fortunately, this is almost never the case. CT and MRI scans are rarely necessary to make a diagnosis, although your health care professional may order one of these tests in some circumstances.

For example, health care professionals are often concerned when patients come to an emergency room for severe headaches. However, several studies have shown that as long as your physical examination is normal, the likelihood of having an abnormal CT or MRI scan is less than 3 percent. If a patient has typical symptoms of a migraine headache and normal findings on examination, a scan is abnormal in less than 0.5 percent of cases. Studies such as these should reassure health care professionals and patients that CT and MRI scans are not necessary for most people who experience headaches.

On the other hand, headaches can sometimes be the first symptom of a serious medical problem. Most health care professionals will consider ordering scans or other specialized tests if a patient has unusual or "red flag" symptoms, such as new headaches in an older adult. If you develop new or worsening headaches and are concerned, be sure to speak with your health care professional about whether CT, MRI or another diagnostic test makes sense.

How does migraine differ from other types of headaches?

Many people mistakenly believe that a migraine is any type of severe headache. Instead, a migraine is a very particular type of headache. Although many migraines are severe, some are quite mild, and many severe headaches are not migraines.

Health care professionals diagnose migraine headaches when some or all of the following features are present:

  • The headaches come in attacks, occurring anywhere from once a month to several times per week.
  • The headaches last anywhere from 4 to 24 hours.
  • The headaches are throbbing and often located on one side of the head (an old term for migraine is "hemicrania," meaning half of the head).
  • The headaches are accompanied by gastrointestinal symptoms, such as nausea, vomiting or loss of appetite.
  • The headaches are preceded by an aura, which is a change in vision (or other sensation) that lasts anywhere from five to 20 minutes.
  • The headaches are made worse by physical activity, bright lights or loud noises.
  • Other family members have similar types of headaches.

Usually a person with migraines has a typical pattern of headache attacks, and making the diagnosis is simple. However, some people have symptoms that don't quite fit migraine but are not typical for other types of headaches. Unfortunately, there is no simple blood test or X-ray to help sort things out. Health care professionals sometimes have to make their best guess about what type of headaches a person is experiencing. As long as there are no worrisome symptoms and the headaches can be controlled, it may not be necessary to make an exact diagnosis.

Can a migraine occur without an aura?

Although an aura (visual disturbance) is a typical symptom of migraine headaches, the majority of migraine sufferers never experience auras. Other people experience auras with only some headaches. A migraine without an aura is sometimes called a "common" migraine.

Interestingly, some people experience migraine auras without any headaches. Other people experience auras for reasons other than migraine.

What is the difference between migraine and cluster headaches?

Migraine and cluster headaches are two unique types of headaches. Although these conditions are similar in some ways, several features point toward a specific diagnosis:

Migraines

Cluster Headaches

The pain of migraines may occur on one or both sides of the head.

The pain of cluster headache almost always occurs on one side of the head.

Migraines appear intermittently but regularly.

Cluster headaches often appear daily for weeks to months, then disappear for months to years.

Migraines last a few hours to a few days.

Cluster headaches are often brief (usually a few hours or less) but may occur up to several times per day.

Migraines are made worse by activity, bright lights and bright noises.

Cluster headaches often feel better if you move around.

Migraines may be accompanied by visual changes (aura) and/or nausea.

Visual changes (aura) and/or nausea are usually absent in cluster headaches.

Eye symptoms are usually absent in migraine headaches.

During cluster headaches, the eye on the same side as the pain may become teary or droopy or develop a small pupil.

Migraines are common and occur in women twice as often as in men.

Cluster headaches are rare and occur mostly in men.

Migraine and cluster headaches appear to be caused by similar but different mechanisms in the brain. They may respond to similar drugs, although certain treatments work particularly well for cluster headaches.

Does the treatment of migraines require prescription drugs?

Many people can control their migraines with over-the-counter drugs or no drugs at all. If you are such a person, there is no reason to take prescription drugs. Many health care profesionals recommend over-the-counter drugs as first-line treatment for their patients.

On the other hand, there are potential advantages to using prescription drugs for headaches, especially if your headaches are severe or not particularly well-controlled. Prescription drugs may be stronger and better able to relieve the pain of a severe headache. Prescription drugs also may be more effective at preventing headaches or stopping them once they begin.

Regardless of how you treat your headaches, be sure to review the drugs you take with your health care professionals. He or she can make sure that you are using the drugs correctly and safely and that there is no conflict between different drugs that you are taking. Be sure to mention all of the drugs that you take, including any herbs, vitamins or supplements that you buy over the counter.

Can stress trigger headaches?

Headaches result from biochemical changes in the brain. Stress can certainly trigger these changes and make headaches more likely to occur. However, stress by itself rarely causes headaches in someone who is not otherwise prone to them. The same is true for other psychological problems such as depression and anxiety.

If you have frequent headaches, managing your stress can be a first step toward bringing your headaches under control. Nonetheless, it is important to recognize that headaches are a genuine medical problem and not simply a product of emotions or an excuse to get out of responsibilities. It is also true that poorly controlled headaches can trigger psychological problems such as depression, rather than the other way around.

Is there treatment available for migraines that are related to the menstrual cycle?

About 70 percent of migraine sufferers are women. Migraine attacks often occur immediately before or during the menstrual period. This is probably the result of changes in hormone levels that are a normal part of the menstrual cycle. Some women experience worsening migraines when they take birth control pills (which contain hormones) or take estrogen therapy for menopause.

Menstrual migraines usually respond to the same treatments as migraines that occur at other times of the month. However, there are several unique treatments for severe menstrual migraines. Because the timing of the headaches is usually predictable, some women take preventive drugs for a few days each month during the time they expect their headaches to occur. Useful drugs include nonsteroidal anti-inflammatory drugs NSAIDs, triptans, beta-blockers, and selective serotonin reuptake inhibitors (SSRIs). Other women respond to specific types of hormonal treatment.

If you suffer from menstrual migraines, be sure to talk with your health care profesional about treatment options. You should speak to your provider if your headaches worsen when you take birth control pills or other types of hormone treatment.

What is the relationship between caffeine and headaches?

Caffeine has a curious relationship to headaches. On one hand, caffeine appears to relieve headaches and is a common ingredient in both over-the-counter and prescription headache remedies.

On the other hand, regular use of caffeine can trigger headaches. People who drink more than four cups of coffee per day seem prone to developing headaches, and people who drink even one or two cups daily may have "withdrawal" headaches on a day when they drink none. Most people get their caffeine from beverages such as coffee, tea or cola, but overuse of caffeine-containing drugs can be a hidden cause of headaches.

If you have frequent headaches, consider cutting caffeine out of your diet completely. The same advice applies to regular use of caffeine-containing drugs such as No-Doz or Excedrin.

Are there ways to treat headaches without drugs?

Absolutely. Many people find relief for their headaches through techniques such as acupuncture, biofeedback and hypnosis. Simple remedies such as ice packs and massage can also be very effective.

There are also many ways to prevent headaches without using drugs.

Why are antidepressant drugs sometimes used to treat headaches?

A number of different drugs can be used to prevent frequent or severe headaches. Many of these drugs were first developed for treating other conditions, such as depression, heart disease or seizures. However, they appear to work for headaches even if a person does not have one of these underlying conditions.

For example, amitriptyline is in a category of drugs known as tricyclic antidepressants. Tricyclic antidepressants treat depression, but they also treat headaches, chronic back pain and nerve injuries. Although amitriptyline was once a common treatment for depression, it is now mainly used to relieve pain. Similarly, the drug valproic acid was originally developed to prevent seizures, but it also prevents migraines.

The package insert (printed information that comes with prescription drugs) often includes useful information. Be sure to read it carefully, and ask your health care professional questions if you are confused about why a drug was prescribed. However, keep in mind that printed information can sometimes be misleading, especially if a drug is used for more than one purpose.

Last updated June 5, 2008




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