Headache

What is headache?

Headache is a condition marked by pain in the head. There are multiple kinds of headache: tension headache; migraine; cluster; trigeminal neuralgia; and rebound headache.

Tension headache

Tension headache is a headache that usually starts in the neck or lower part of the back of the head and progresses around to the front of the head. It is often on both sides of the head. Pain can also occur in the shoulders, neck, or jaw. Often described as a tight band or even a vice-like grip, the pain of tension headaches can range in intensity from mild to very severe.

Tension headaches are the most common form of headache.

The cause of tension headaches is muscle tension, usually due to stress. Anxiety and depression can also lead to persistent muscle tension, which then produces a headache.

Sometimes, tension headaches develop as a result of having another type of headache. For instance, someone having a migraine can subsequently develop a tension headache. The body’s response to the pain of the migraine is for the muscles to become tense. If the migraine is long lasting, then the persistent muscle tension that occurs as a result of the pain of the migraine can itself generate a tension headache.

Many chronic daily headaches develop in this manner. Whether the primary headache is tension-related or migraine or what have you, the pain of the primary headache leads to muscle tension, which generates a tension headache. In turn, the pain of the secondary tension headache leads to further muscle tension, which generates yet again another tension headache. A vicious cycle of pain causing pain by way of recurrent muscle tension occurs. As such, many chronic daily headaches are either completely tension-related or what’s called a ‘mixed headache,’ such as mixed migraine and tension headache.

Migraine

Migraine headaches are a type of headache that usually centers on one side of the head. Sensitivity to light and sound, nausea and vomiting are also common with migraine headaches. The pain of migraine headaches is typically severe.

An aura often precedes the onset of pain in migraines. An aura is a visual disturbance marked by a temporary blind spot or seeing stars or distinct blurry lines that cut across the visual field.

Onset of a migraine headache can be abrupt. Different foods, drinks, and activities can trigger a migraine. Some of the more common are the following:

  • Bright lights
  • Red wine
  • Aged cheeses
  • Abrupt caffeine withdrawal
  • Rigorous exercise
  • Upon relaxing after a stressful period of time
  • Going too long without eating
  • Hormonal changes during the menstrual cycle

The cause of migraine headaches is not known.

Cluster headaches

Cluster headaches are a type of headache that centers in and around one eye. The eye often gets tearful. Sometimes, the nostril on the same side as the pain can also become stuffy. The pain is typically intense and severe.

Cluster headaches occur on a repetitive basis over a month or more, followed by a period of being headache-free.

The cause of cluster headaches is not known.

Trigeminal neuralgia

Trigeminal neuralgia (TN) is a condition that causes pain in the face and head. The pain is usually on one side of the face. The pain is related to the trigeminal nerve, which runs from the brain to the side of the face.

The pain of TN is often intense and short-lived. Patients often describe the pain as electrical in quality. While often the pain occurs in a burst that lasts for seconds, sometimes the pain can occur in repetitive bursts that last for hours to days.

There is no single cause of TN. It is thought that compression of the trigeminal nerve by an enlarged blood vessel can cause it. It is also associated with aging. Multiple sclerosis is also sometimes associated with it.

Rebound headache

Rebound headache (also referred to as medication overuse headache) is a type of headache that occurs as a result of frequent use of medications, which are taken for other types of headaches. Some medications tend to produce rebound headaches more often than other medications. As a general rule, medications that are used on an as-needed basis once a headache starts tend to produce rebound headache, particularly if they are used frequently. Medications that prevent headaches from occurring in the first place do not tend to produce rebound headaches.

Medications that can cause rebound headache when taken too often are the following:

  • Barbiturates
  • Opioids, like oxycodone or hydrocodone
  • Ergotamines
  • Triptans
  • Acetaminophen
  • Non-steroidal anti-inflammatories
  • Over-the-counter medications containing caffeine

This list is not exhaustive. Conventional wisdom suggests that barbiturates, opioids, ergotamines, and triptans have the greatest capacity for developing rebound headache.

Rebound headache is a common way headaches of all types become chronic daily headaches. A person may have, for instance, migraine headaches on a periodic basis and in response he or she takes an as-needed medication. If it occurs too often, a rebound headache occurs and the medication is again taken. Another rebound headache occurs and a vicious cycle begins. The very thing that the patient takes to treat headache is itself causing headache.

Central sensitization

Central sensitization is a highly reactive state of the nervous system, which amplifies pain. It can occur with most any pain disorder. It is likely to play a role in the occurrence of all forms of headache as well as their possible progression to chronic daily headaches. It is apt to be an important factor in tension headaches.1 It is likely to play a role in migraine headache.2, 3 Central sensitization has been implicated in cluster headaches4 and trigeminal neuralgia.5. 6 

Is there a cure for headache?

As traditionally defined, there are no cures for the different types of headaches. Goals of care are to reduce the frequency and intensity of headache.

Therapies & Procedures for headache

Treatment for headaches is dependent on the type of headache.

Common treatments for tension headaches are acetaminophen, non-steroidal anti-inflammatory medications, stress management and relaxation therapies. Common treatments for chronic daily tension headaches are the afore-mentioned treatments but also antidepressant medications, muscle relaxants, opioid medications, mild aerobic exercise, cognitive behavioral therapy, and chronic pain rehabilitation programs.

Common treatments for migraine headache are acetaminophen, non-steroidal anti-inflammatory medications, triptan medications, ergotamine medications, avoidance of triggers, stress management, and relaxation therapies. Common treatments for chronic daily migraines or mixed migraine-tension headaches are the afore-mentioned treatments but also antidepressant medications, anticonvulsant medications, opioid medications, mild aerobic exercise, cognitive behavioral therapy, and chronic pain rehabilitation programs.

Common treatments for cluster headache are acetaminophen, non-steroidal anti-inflammatory medications, triptan medications, stress management, and relaxation therapies. Common treatments for chronic cluster headaches or mixed cluster-tension headaches are the afore-mentioned treatments but also antidepressant medications, anticonvulsant medications, opioid medications, mild aerobic exercise, cognitive behavioral therapy, and chronic pain rehabilitation programs.

Common treatments for TN are anticonvulsant medications, neuroablation procedures, surgery, and chronic pain rehabilitation programs.

Treatment for rebound headache is to taper off the medication that is suspected to be causing the headache and to do so under the guidance of a prescribing provider. Typically, such tapering is done in the context of the patient participating in a chronic pain rehabilitation program or, at least, within the context of engaging in cognitive behavioral therapy with a chronic pain rehabilitation psychologist.

References

1. Jensen, R. (2003). Peripheral and central mechanisms in tension-type headache: An update. Cephalalgia, 23, 49-52.

2. Chen, W., Wang, S., Fuh, J., Lin, C., Ko, Y., & Lin Y. (2011). Persistent ictal-like visual cortical excitability in chronic migraine. Pain, 152, 254-258.

3. Stankewitz, A., & May, A. (2009). The phenomenon of changes in cortical excitability in migraine is not migraine-specific – A unifying thesis. Pain, 145, 14-17.

4. Donnet, A., et al. (2007). Chronic cluster headache: A French clinical descriptive study. Journal of Neurology, Neurosurgery, and Psychiatry, 78, 1354-1358.{

5. Hu, W. H., Zhang, K., & Zhang, J. G. (2010). Atypical trigeminal neuralgia: A consequence of central sensitization? Medical Hypotheses, 75, 65-66.

6. Watson, J. C. (2007). From paroxysmal to chronic pain in trigeminal neuralgia: Implications of central sensitization. Neurology, 69, 817-818.

Date of publication: April 27, 2012

Date of last modification: October 23, 2015

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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