What Kind of Headache Do I Have?

The term headache applies to pain involving the head or face. In any given year, more than 90 percent of us will experience at least one headache. The causes of headache range from short-lived conditions such as viral infections, minor head injury and hangovers to temporarily disabling disorders like migraine, to devastating disorders like subarachnoid hemorrhage headache.

There is a three-step approach to thinking about headaches. The first step is to assess the likelihood of secondary headache, or headache with an underlying cause. The second step is to assess headache frequency and duration. The third step is to identify the most likely specific disorder within a group. Remember that accurate headache diagnosis requires a medical evaluation and sometimes the use of diagnostic tests. When in doubt, see your doctor.

Step 1: Do my headaches have a serious or life-threatening cause?

Secondary headaches are attributable to an underlying disorder, and should be suspected if red flags, like a very sudden headache onset, are present. Comfort signs suggest that a primary headache disorder is likely. These include a long duration of similar headaches, worsening of headache on the first few days of menstrual flow, a positive family history of similar headaches and a typical response to treatment.

If you have red flags, please see your doctor, as diagnostic tests are usually required to identify or exclude the secondary headache disorders. Remember that many people have more than one kind of headache. If your headaches change by becoming more frequent or severe, for example, see your doctor. This could be the new onset of a new secondary headache disorder superimposed on a background of headache.

Step 2: Determine your headache frequency and duration.

After excluding a secondary headache disorder, the next step is to identify your primary headache grouping. These groups are defined based both on the number of headache days per month and on the average duration of each attack. Based on headache days, there are two broad categories: episodic headache with less than 15 headache days per month and chronic frequent headache with 15 or more days per month. Short duration attacks are those that last less than four hours on average. Long duration attacks last four hours or more.

The most common group is the episodic headaches of long duration, which are comprised of migraine and tension type headache. The chronic frequent headache of long duration group includes chronic migraine, chronic tension type headache and daily persistent.

Step 3: What is my type of headache?

Episodic long duration headache, migraine and tension type headache (also known as tension headache or stress headaches) are the most common forms of headache. Migraine is the most disabling of the primary headache disorders, affecting about 12 percent of the U.S. population, and occurs most frequently without aura -- neurologic symptoms, which are commonly visual, and last between five and 60 minutes. Aura features are typically both positive (flashing lights, zig-zag lines) and negative (a graying out of vision). These symptoms are fully reversible. Other common aura symptoms could include tingling, numbness or difficulty with speech or movement, often on just one side of the body.

Headache may begin during the aura or within 60 minutes of its resolution. More common than aura are symptoms that begin hours or days before headache, such as fatigue, neck discomfort, food cravings, drowsiness, diarrhea or constipation. These symptoms occur in about 60 percent of people with migraine.

The headache phase of migraine, with or without aura, typically lasts from four to 72 hours. Migraine is a diagnosis of inclusion, in that certain patterns of pain and associated symptoms are required. The pain features include at least two of the following four characteristics: (1) unilateral location, (2) pulsatile or throbbing quality, (3) moderate-severe pain intensity and (4) worsened by or avoidance of routine physical activity (e.g., walking, bending, lifting or climbing stairs). The associated symptoms can include either nausea or vomiting, or both sensitivity to light and sound. Migraine is also a diagnosis of exclusion in that secondary causes of headache must be excluded based on history and physical exam or the judicious use of diagnostic tests.

Tension type headaches are the most common of the primary headache disorders. Head pain is usually a pressure pain or steady ache, and can be mild to moderate in intensity. Tension type headaches are not aggravated by physical activity or sensitivity to light and sound.

Conclusion

The differential diagnosis of headache requires a careful history of headache onset, location, quality of pain, quantity of pain, duration, frequency and associated symptoms. Headache sufferers with red flags should seek medical advice. Even when a primary headache disorder has been diagnosed, possible secondary headache diagnoses should be considered when headaches change in characteristics or new symptoms develop.

To help keep track of headache symptoms, we encourage patients to write symptoms down in a diary or log prior to engaging a doctor. A sample log can be found here.

Dr. Richard Lipton is co-director of the Montefiore Headache Center, an interdisciplinary subspecialty center focused on headache, patient care, research and education. His headache research focuses on the epidemiology of migraine and has evaluated trigger factors for headache attacks and risk factors for headache progression. Dr. Lipton holds leadership positions in several professional societies, and is a Past-President of the American Headache Society.