Most people get a headache now and then. Sometimes it is a symptom of a cold or flu. Sometimes it is triggered by stress, muscle tension, or even a hangover. Most of the time, a headache doesn’t last long enough or hurt enough to stop you from doing what you usually do.
If you have a severe headache that is your first or worst ever, you should seek immediate medical treatment because it may be a sign of stroke or brain injury.
If you have headaches that are very painful, last a long time, or occur often, it is a good idea to see a doctor. You may be one of many people (1 out of every 7) who have headache disorders.
The most common headache disorder is called migraine, and it can keep you from doing your usual activities. A migraine is usually a throbbing pain on one side of the head but there may be other types of pain. It can also be painful on both sides of the head for some people. Just before and during migraines, you may feel sick or nauseous, have blurry vision, or be sensitive to bright lights or loud sounds. A minority of migraine sufferers experience visual zig zags or a blind spot preceding the head pain. Migraines can last for many hours or even days.
Some people notice they get migraines after they eat or drink certain things, like chocolate or red wine. These are considered triggers. Other triggers include bright lights, having a sleepless night, a specific smell, or stress. Triggers can be different for different people and no single trigger has ever been proven to make migraine occur. Stress is the most commonly reported trigger.
Another type of headache that is much less common is cluster headache, considered to be one of the five most painful medical conditions. Usually, a cluster headache wakes someone in the middle of the night with severe pain around one eye, along with eye tearing and redness, a droopy eyelid and a stuffy nose. Cluster headaches may occur frequently for days, weeks, or months, then stop for months or even years. They can also become almost constant.
There are other types of headaches and some are caused by medical problems like infections, teeth grinding, concussion, brain bleed, tumor, stroke, or thyroid conditions. These are called secondary headaches.
If you have headaches less than 10 to 15 days in a month, they are considered episodic. If you have them on more than 10 to 15 days in a month, they are considered chronic.
If you get bad or frequent headaches, try to write down how often they happen and what it is like for you. Then talk to a doctor. Since there are many ways to treat headaches—including many types of medications—you might consider seeing a headache specialist.
The doctor will ask questions about the “history” of your headaches.
Your doctor will probably perform a physical exam, looking for signs of illnesses that can cause headaches. You may also need to have blood tests or a brain imaging study like an MRI or a CT scan.
Unfortunately, there is no test yet that can tell for sure that you have a headache disorder. This means doctors must use their knowledge and experience to make a clinical diagnosis. In practice this means once doctors have ruled out other causes, they compare your headaches to other peoples’ headaches and then make a diagnosis and recommend a treatment.
Headaches can be treated when they happen to reduce pain and discomfort and the headache last a shorter time. This considered acute treatment. For people with chronic headaches, there are also preventive treatments that can make headaches happen less frequently.
For all headaches that are not severe enough to warrant an emergency room visit, acute medications include over-the-counter pain medications such as ibuprofen and acetaminophen. There are also prescription medicines for acute treatment. Drugs called triptans are used most often for migraine, but these can not be used by people who have cardiovascular risk factors. People with cluster headaches may need to be prescribed oxygen treatment and medicines that enter the blood stream rapidly (injections, nasal sprays) for their headaches.
A danger of acute medicines is that they can actually cause more headaches if they are taken more than 10 to 15 times a month. These are called rebound headache or medication-overuse headaches. It is a good idea for anyone who has headaches this often to see a headache specialist.
Neurostimulation is a newer type of treatment for migraine and other headaches. Small devices either held against your neck or back of your head, or worn on your forehead deliver impulses to calm the brain’s pain area. These may work well for some people and some have been approved for use in both adolescents and adults.
For people who have headaches more than 4 times a month, preventive treatments can be considered. These include drugs that were developed to treat high blood pressure, epilepsy, depression, and other medical problems, but also proven useful in preventing headaches.
Injections of botulinum toxin into the muscles of the head and neck help some people with chronic migraine. Injecting anesthesia directly into the nerves of the head and neck in a nerve block procedure can also help some people. The nerve stimulators that can be used for acute treatment may also prevent both migraine and cluster headache for some people.
Recently, a new preventive treatment has been developed specifically for migraine. This class of treatments, the monoclonal antibody CGRP inhibitors, act on a chemical known to be released by pain-sensitive nerves during migraine. These are prescription drugs that you self-inject every 1 to 3 months. Experience with CGRP inhibitors is limited because of how new they are. So far, however, they seem to have few risks or side effects.
All treatments have different benefits, risks, and side effects, and it is very important to discuss these with your doctor.
One of the most important things you can do is develop a treatment plan with your doctor that you will follow. Any treatment should be tried for 2 to 3 months before making changes because some drugs take time to work. It is also important to take medication as directed and tell your doctor about any other medications you take. Include nutritional and herbal supplements because just like drugs, each medicine or supplement can affect how another one does or doesn’t work.
If you have side effects from your medicine, such as tiredness, racing heartbeat, nausea, or dizziness, talk to your doctor before making changes. Remember that taking acute treatments too often can make more headaches happen! Talk to your doctor if you need medicine more than 10 times in a month. Keeping a migraine diary helps you recognize progress, and you can refer to it when talking with your doctor. In your diary, include the times of day when headaches start and end, the location of your pain, the type and intensity of your pain, the medication you take and how well it’s working, as well as stress, fatigue, diet, or sleep habits that trigger your headaches.
Healthy living habits enhance your overall wellbeing and can be powerful weapons against headaches. It has been shown that getting enough sleep every night and sleeping regularly (getting up and going to sleep at the same times every day) can reduce how often some people have headaches.
There is no specific diet shown to reduce headaches, but drinking enough water to be fully hydrated does reduce headaches. Some minerals and vitamins appear to be helpful in treating migraines,and are being studied, including magnesium, riboflavin, and coenzyme Q10.
Getting regular exercise and spending time with positive, supportive people havealso been shown in some studies to help people with brain diseases live well.
Headache Horizons: Rebound Abounds in Chronic Migraine
Despite clear definitions in guidelines, many questions remain regarding medication-overuse headaches in the context of chronic migraine.
Peter McAllister, MD
Convention Question: Has CGRP-Related Treatment Changed Your Practice?
Answers from attendees of the American Headache Society 61st Annual Meeting in Philadelphia, PA, July 11-14, 2019.
Headache Highlights: From Killer to Cure—Botulinum Toxin as Therapy Turns 30
Botulinum toxin, once known as the sausage poison, has 30th birthday as therapy.
Peter McAllister, MD
About the Cover Artist
Focused on finding life’s gifts, Emily J. Shapiro’s artwork captures the joy in life and nature she insists on, despite living with migraine.
Last Word: Eptinezumab on the Horizon
Alder BioPharmaceuticals has submitted an application for approval of an antibody to CGRP, unique for its 30-minute quarterly infusion and more.
Bob Azelby, MBA
Cluster Headache Acute Therapies
Despite strong evidence for high-flow oxygen, subcutaneous sumatriptan, and zolmitriptan nasal spray, patients often receive less-than-adequate abortive treatment.
Brian E. McGeeney, MD, MPH, MBA
Cluster Headache Preventive Therapies
The challenges of cluster headache lead to treatments and further understanding.
Emmanuelle A. D. Schindler, MD, PhD; and Christopher Gottschalk, MD
Cannabis and Cannabinoid Therapies for Headache
Shown effective for treatment of pain, Cannabis may have benefits for patients with headache, but more research is still needed.
Niushen Zhang, MD
Behavioral and Integrative Therapies for Headache
Many patients who may benefit from these treatments may not be aware nonpharmacologic approaches exist.
Mary Motwani, PhD; and Deena Kuruvilla, MD
Neuromodulation Therapies for Headache
Neuromodulation devices creates potential paradigm shift in headache medicine.
Umer Najib, MD, FAHS; Jessica Frey, MD; and David B. Watson, MD, FAHS, FAAN
Procedural Treatments for Headache Disorders
Botulinum toxin injections, nerve blocks, and trigger point injections are safe and effective in-office treatment options.
Regina Krel, MD; and Paul G. Mathew, MD, DNBPAS, FAAN, FAHS
Migraine During Pregnancy
Developing plans for treatment during pregnancy before conception can relieve stress for both patient and provider.
Kate Onorato, MD; Carrie Dougherty, MD, FAHS; and Jessica Ailani, MD, FAHS
Migraine in Children
Headache is common in children and adolescents and there are exciting developments in diagnosis, classification, and treatment.
Lauren Doyle Strauss, DO, FAHS; and Scott Otallah, MD
Migraine Acute Therapies
Acute treatment of migraine improves daily function and reduces associated disability and risk of transformation to chronic migraine.
Rashmi B. Halker Singh, MD; Amaal J. Starling, MD; and Juliana VanderPluym, MD
Migraine Preventive Therapies in Development
The field of headache medicine is full of promise with more migraine-specific preventive therapies in development.
Aniket Natekar, MD, MSc; Malya Sahu, BSc; Hsiangkuo Yuan, MD, PhD; and Stephanie Nahas, MD, MSEd, FAHS, FAAAN
Migraine Preventive Therapies
With new—and first-in-class—migraine-specific treatments, preventive treatment of migraine is changing quickly.
Charisse Litchman, MD, FAHS; and Sirisha Sanamandra, MBBS
Are we underdiagnosing migraines?
Cynthia E. Armand, MD; Alina Masters-Israilov, MD; and Richard B. Lipton, MD
Guest Medical Editor's Page
Headache in the Spotlight
New treatments are bringing the field of headache medicine to center stage.
Deena Kuruvilla, MD
Headache Horizons: Migraine Work in Translation
From discovery of CGRP to the monoclonal antibodies of today and -gepants of tomorrow, basic science has been translated to clinical progress over just 3 decades.
Richard B. Lipton, MD
Marc Nuwer, MD, PhD
Chrystal Reed, MD, PhD
Peter McAllister, MD