Headache pain affects just about everyone, causes and treatments vary

Businesswoman with intense stress and painful headache. Woman in job problems.

You’ve had one, I’ve had one, almost everyone has had a headache – it’s the most common form of pain. It’s also a big reason why people miss school or work to go to the doctor. In fact, globally about 50% of adults have had at least one headache within the last year.

According to the World Health Organization, headaches affect “people of all ages, races, income levels and geographical areas.” They also inflict a burden of impaired quality of life, personal suffering, and financial cost. The constant fear of, and living with, repeated headache attacks can damage one’s family and social lives, and employment. There may also be a higher predisposition to other illnesses, such as anxiety and depression.

However, there is a difference between a single headache and a headache disorder, which is characterized by recurrent headaches. A headache is a very painful and often disabling symptom of a primary headache disorder, which includes migraine, tension-type headache, and cluster headache. Headaches can also be secondary to or caused by other conditions, most commonly rebound (or medication-overuse) headache.

In this article, we’ll look at the most common types of headaches and highlight some of the more recent research, including:

Migraine headache

Migraines typically are intense, pounding headaches that usually begin in the forehead, the side of the head, or around the eyes, and can last for hours or sometimes days. The pain gradually gets worse, and most movement, activity, loud noises, or bright lights appear to make it hurt more. It’s common to have nausea and vomiting. The frequency of the migraines is individual-specific and women are more likely to have migraines than men.

No one knows the exact cause of migraines, but there is some evidence that changes in the levels of the body chemical, serotonin, may play a role. Serotonin can affect the blood vessels in the body and when its levels fall, the chemical causes the blood vessels to swell, leading to pain and other problems. It’s also possible that migraines follow a spreading pattern of electrical activity in the brain.

There are several factors that can trigger your migraines, like:

  • Hormonal changes in women: estrogen fluctuations before or during menstruation, pregnancy, menopause, or even hormonal medications;
  • Foods: aged cheeses, salty foods, and processed foods, as well as skipping meals or fasting;
  • Drinks: alcohol (especially wine) and highly caffeinated beverages;
  • Stress: at work or home;
  • Sensory stimuli: bright lights, sun glare, loud sounds, and strong smells;
  • Changes in wake-sleep pattern: missing or getting too much sleep;
  • Physical factors: intense physical exertion, including sexual activity;
  • Changes in environment: change of weather or barometric pressure; and
  • Medications: oral contraceptives and vasodilators (i.e. nitroglycerin).

Migraines typically begin in childhood, adolescence, or early adulthood. The symptoms include four stages, but you may not experience all four.

Prodrome

One to two days prior to a migraine, you may experience subtle warning signs. They may include:

  • Constipation;
  • Mood changes (from depression to euphoria);
  • Food cravings;
  • Neck stiffness;
  • Increased thirst and urination; and
  • Frequent yawning.

Aura

Auras may occur before or even during your migraine; most people do not experience an aura. Your symptoms usually begin gradually and build up over several minutes, lasting 20 to 60 minutes. Some examples are

  • Visual phenomena, like seeing various shapes, bright spots, or flashes of light;
  • Vision loss;
  • Pins and needles sensation in an arm or leg;
  • Weakness or numbness in the face or one side of the body;
  • Difficulty speaking;
  • Hearing noises or music; and
  • Uncontrollable jerking or other movements.

You may also have an aura with limb weakness (hemiplegic migraine).

Attack

The migraine itself usually lasts from four to 72 hours if it’s not treated. How frequently you get them depends on you. Your symptoms during the attack may include:

  • Pain on one or both sides of your head;
  • Pain that feels throbbing or pulsing;
  • Sensitivity to light, sounds, and sometimes smells and touch;
  • Nausea and vomiting;
  • Blurred vision; and
  • Lightheadedness, sometimes followed by fainting.

Post-drome

Also known as the final phase, the post-drome phase occurs after the attack and you may feel washed out or even elated. For around 24 hours, you may feel:

  • Confusion;
  • Moodiness;
  • Dizziness;
  • Weakness; and
  • Sensitivity to light and sound.

Unfortunately, there are several factors that increase your risk of developing migraines. If you have a family member with migraines or if you are an adolescent (migraines usually start around this age and peak during your 30s) your risk goes up. If you are a woman you’re three times more likely than a man to have migraines. Also, if you are a woman experiencing any sort of hormonal changes (i.e. menstruation, pregnancy, menopause, etc.), you have a higher risk.

Some ways you can try to prevent migraines (although there is no surefire way) are

  • Eat regularly and don’t skip meals;
  • Keep a regular sleep schedule;
  • Exercise regularly; and
  • Keep a headache diary to learn about your triggers and helpful treatments.

When it comes to treatment, your individual strategy will depend on the frequency and severity of your migraines, how much your migraines negatively impact your life, and any other medical conditions you have.

There are two different types of medications you may use – pain-relieving (or acute) medications and preventive medications.

Acute medications

You take these drugs as soon as you start experiencing symptoms of a migraine to have the best results. They are designed to stop the symptoms of an attack. Different types are listed below:

Be aware that if you take OTC pain relievers too often or for long periods of time, you can develop ulcers, gastrointestinal bleeding, and rebound headaches.

Preventive medications

Preventive medications are used to reduce the frequency, severity, and length of migraines, and may increase the effectiveness of pain-relieving medications used during an attack. They may take several weeks for you to see a benefit. You may be a candidate for preventive therapy if:

  • You have four or more debilitating attacks a month;
  • The attacks last more than 12 hours;
  • Pain-relieving medications aren’t helping; and
  • Your migraine symptoms include a prolonged aura or numbness and weakness.

Preventive medications don’t always stop your migraines completely and they may cause serious side effects. Your healthcare provider may recommend daily medication or only when a predictable trigger (i.e. menstruation) is approaching. If you have good results, they may also recommend tapering off the medication to see if your migraines return. Below are the most common preventive migraine drugs:

  • Cardiovascular drugs: Beta Blockers (Inderal LA, Innopran XL, Lopressor, Betimol, etc.), Calcium Channel Blockers (Calan, Verelan, etc.), Angiotensin-Converting Enzyme Inhibitor (Zestril);
  • Antidepressants: Tricyclic Antidepressants (Amitriptyline), Serotonin-Norepinephrine Reuptake Inhibitor (Effexor XR);
  • Anti-seizure drugs: Depacon, Topamax;
  • Botox;
  • Pain relievers: Naproxen.

Risks to pregnant women

In a study of women in Denmark with and without migraines who became pregnant, migraines were associated with an increased risk of pregnancy-associated hypertension disorders in the mother. Also, in newborns, maternal migraine was associated with an increased risk of a variety of adverse outcomes, including low birth weight, preterm birth, cesarean delivery, respiratory distress syndrome, and febrile seizures.

The Headache study included 22,841 pregnancies among women with migraine (including 16,861 with a liveborn offspring) and 228,324 age- and conception-year matched pregnancies among women without migraine (including 170,334 with a liveborn offspring).

Treated migraine was not linked with higher risks of adverse outcomes compared with untreated migraine. This suggests that migraine itself, rather than its treatment, is associated with pregnancy complications.

“Migraine is a disabling condition, common among women of reproductive age. Accumulating evidence shows that migraine in pregnancy may lead to several adverse outcomes in the mother and child, but treatment may alleviate these risks,” said lead author Nils Skajaa, Epidemiologist Department of Clinical Epidemiology, Aarhus University Hospital.

Losing weight may help

For migraine sufferers with obesity, losing weight can decrease headaches and improve quality of life, researchers from Italy and the United States report. The results of their meta-analysis were presented Saturday, March 23 at ENDO 2019, the Endocrine Society’s annual meeting in New Orleans, La.

“If you suffer from migraine headaches and are obese, losing weight will ameliorate the quality of your family and social life as well as your work and school productivity. Your overall quality of life will greatly improve,” said lead study author Claudio Pagano, M.D., Ph.D., an associate professor of internal medicine at the University of Padova in Padova, Italy.

“Weight loss in adults and children with obesity greatly improves migraine headache by improving all the main features that worsen migraineurs’ quality of life,” he added. “When people lose weight, the number of days per month with migraine decreases, as does pain severity and headache attack duration.”

To investigate the effects of weight loss achieved through bariatric surgery or behavioral intervention on migraine frequency and severity, Pagano and his colleagues reviewed the standard online medical research databases for studies that considered pain intensity, headache frequency, attack duration, disability; and BMI, BMI change, intervention (bariatric surgery versus behavioral), and population (adult versus pediatric).

In a meta-analysis of the 473 patients in the 10 studies that met the researchers’ inclusion criteria, they found that weight loss was linked with significant reductions in headache frequency, pain intensity and disability (all p<0.0001); as well as attack duration (p=0.01).

Migraine improvement was not linked with either degree of obesity at baseline or amount of weight reduction. Also, the effect on migraine was similar when weight reduction was achieved through bariatric surgery or behavioral intervention and was comparable in adults and children.

“Weight loss reduces the impact of conditions associated with obesity, including diabetes, hypertension, coronary heart disease, stroke and respiratory diseases,” Pagano said. “Obesity and migraine are common in industrialized countries. Improving quality of life and disability for these patients will greatly impact these populations and reduce direct and indirect healthcare costs.”

The mechanisms linking obesity, weight loss and migraine headache remain unclear, according to the authors, but they may include alterations in chronic inflammation, adipocytokines, obesity comorbidities, and behavioral and psychological risk factors.

May increase stroke risk

Migraine with aura was associated with an increased risk of ischemic stroke in the Atherosclerosis Risk in Communities study, but a recent post-hoc analysis published in Headache reveals unexpected results suggesting that onset of such migraines before age 50 years is not associated with such risk. Later onset of migraine with aura was linked with a higher risk, however.

The analysis included 447 migraineurs with aura (MA) and 1,128 migraineurs without aura (MO) among 11,592 participants (elderly men and women with a history of migraine). Over 20 years, there was a twofold increased risk of ischemic stroke when the age of MA onset was 50 years or older when compared with no headache. MA onset before 50 years old was not associated with stroke. Also, MO was not associated with increased stroke risk regardless of age of onset.

In the elderly population in this study, the absolute risk for stroke in MA was 37/447 (8.27 percent) and in MO was 48/1,128 (4.25 percent).

“I think clinically this is very meaningful, as many individuals with a long history of migraine are concerned about their stroke risk, especially when they get older and when they have other cardiovascular disease risks,” said lead author Dr. X. Michelle Androulakis, Chief of Neurology at WJB Dorn VA Medical Center, in South Carolina. “Cumulative effects of migraine alone–with onset of migraine before age of 50–did not increase stroke risk in late life in this study cohort. On the contrary, the recent onset of migraine at or after age 50 is associated with increased stroke risk in late life.”

Alcohol may be a trigger

In a European Journal of Neurology study of 2,197 patients who experience migraines, alcoholic beverages were reported as a trigger by 35.6 percent of participants.

Additionally, more than 25 percent of migraine patients who had stopped consuming or never consumed alcoholic beverages did so because of presumed trigger effects. Wine, especially red wine (77.8 percent of participants), was recognized as the most common trigger among the alcoholic beverages; however, red wine consistently led to an attack in only 8.8 percent of participants. Time of onset was rapid (less than three hours) in one third of patients, and almost 90 percent of patients had an onset in under 10 hours independent of the type of alcoholic beverage consumed.

The authors noted that it can be debated if alcohol is a factual or a presumed trigger. Additional studies are needed to unravel this relationship.

“Alcohol-triggered migraine occurs rapid after intake of alcoholic beverages, suggesting a different mechanism than a normal hangover,” said senior author Dr. Gisela Terwindt, of the Leiden University Medical Center, in the Netherlands.

Tension-type headache

Tension-type headaches occur in about three-fourths of the general population, making them the most common form. You can have the occasional mild headache to an extremely disabling headache on an everyday basis.

The cause of these headaches is unknown and research suggests that muscle contractions in the face, scalp, and neck do not contribute to them. Instead, the most common theory is that sufferers have a heightened sensitivity to pain and that stress is the biggest trigger.

Tension headache symptoms include:

  • Dull, aching head pain;
  • A sensation of tightness or pressure across your forehead or on the sides and back of your head; and
  • Tenderness on your scalp, neck, and shoulder muscles.

There are two categories of tension headaches – episodic and chronic. Episodic tension headaches last anywhere from 30 minutes to a week, and frequent episodic tension headaches occur less than 15 days a month for at least three months. This type of headache may become chronic. Chronic tension headaches, meanwhile, last hours and may be continuous; they also occur for 15 or more days a month for at least three months.

Many times, it can be hard to differentiate migraines from tension headaches. When distinguishing the two, it’s important to note that visual disturbances, nausea and vomiting, and an increased sensitivity to light or sound typically don’t accompany tension headaches. Also, physical activity usually doesn’t aggravate tension headache pain.

When it comes to preventing your tension headaches, living a healthy lifestyle, regular exercise, and the below techniques may help:

  • Biofeedback training: technique used to control body responses that help decrease your pain;
  • Cognitive behavioral therapy: talk therapy to help manage your stress and possibly reduce the frequency and severity of your headaches; and
  • Other relaxation techniques: deep breathing, yoga, meditation, etc. that help you relax.

When it comes to treatment, your individual strategy will depend on the frequency and severity of your tension-type headaches, how much they negatively impact your life, and any other medical conditions you have.

There are two different types of medications you may use – pain-relieving (or acute) medications and preventive medications.

Acute medications

  • Pain relievers: Aspirin, Advil, Motrin, Aleve, Naproxen, Indocin, Ketorolac Tromethamine;
  • Combination medications: Excedrin Tension Headache, etc.; and
  • Triptans and narcotics: Imitrex, Maxalt, Axert, Amerge, Zomig, Frova, Relpax. Narcotics are rarely used due to their side effects and potential for abuse and dependency.

Preventive medications

  • Tricyclic antidepressants: Amitriptyline, Protriptyline;
  • Other antidepressants: Effexor XR, Remeron; and
  • Anti-seizure medications and muscle relaxants: Topamax.

Cluster headache

Headaches that occur in a cycle or clusters and are one of the most painful types of headaches; they are known as cluster headaches. They will usually wake you in the middle of the night with intense pain in or around one eye on one side of your head. The cluster periods (or bouts of frequent attacks) last from weeks to months, and are followed by periods of remission without headaches. Remission periods can last for months or even years.

Doctors don’t know the exact cause of cluster headaches, but there seems to be a relationship between your body’s sudden release of histamine (a chemical released during allergies) or serotonin (a chemical made by nerve cells). There may also be an issue with the hypothalamus (at the base of your brain). Typically, men are affected more than women, headaches are most common in your 20s through middle age, and headaches tend to run in families.

Some triggers for these headaches may include:

  • Alcohol and cigarette smoking;
  • High altitudes (climbing and air travel);
  • Bright light (even sunlight);
  • Physical activity;
  • Hot weather or hot baths;
  • Foods high in nitrites (i.e. bacon and preserved meats);
  • Certain medications; and
  • Cocaine.

Cluster headaches strike quickly without warning, though you may have migraine-like nausea and aura. Usual symptoms are

  • Excruciating pain, generally in or around one eye, but may radiate to other areas of your face, head, neck, and shoulders;
  • One-sided pain;
  • Restlessness;
  • Excessive tearing;
  • Redness in the eye on the affected side;
  • Stuffy or runny nose on the affected side;
  • Forehead or facial sweating;
  • Pale skin or flushing on your face;
  • Swelling around the eye on the affected eye; and
  • Drooping eyelid.

Unlike someone experiencing a migraine, people with cluster headaches are likely to pace or sit and rock back and forth. You may experience sensitivity to light and sound (migraine-like symptoms), but it’s usually only on one side.

When you are in a cluster period, it generally lasts six to 12 weeks and the starting date and duration may be consistent (i.e. it may occur seasonally every spring). Most people have episodic cluster headaches, during which the headaches occur for one week to a year and then you have a remission period for up to a year. If you experience chronic cluster periods, they may continue for more than a year and your remission period may last less than a month.

While in a cluster period:

  • Headaches usually occur every day, sometimes several times a day;
  • A single attack can last from 15 minutes to three hours;
  • Attacks often occur at the same time each day; and
  • Most attacks occur at night, usually one to two hours after going to bed.

The pain usually suddenly ends and people are mostly pain-free, but exhausted after the attacks.

Unfortunately, there are several risk factors for developing cluster headaches. If you are a man, if you are between the ages of 20 and 50, if you are a smoker, if you drink alcohol, and if you have a parent or sibling with the disease, your likelihood of having cluster headaches is higher.

When it comes to treatment, your individual strategy will depend on the frequency and severity of your cluster headaches, how much they negatively impact your life, and any other medical conditions you have.

There are two different types of medications you may use – pain-relieving (or acute) medications and preventive medications.

Acute treatments

  • Oxygen: inhaling oxygen provides dramatic relief to most who use it;
  • Triptans: injectable Imitrex, Zomig (nasal spray or tablet);
  • Octreotide;
  • Local anesthetics: intranasal Xylocaine; and
  • Dihydroergotamine: injectable DHE 45.

Preventive treatments

  • Calcium Channel Blockers: Calan, Verelan, etc.;
  • Steroids: Prednisone, etc.;
  • Lithium;
  • Nerve block;
  • Melatonin; and
  • Antiseizure medications: Topamax, Qudexy XR.

Rebound headache

Rebound (or medication-overuse) headaches occur with the regular, long-term use of medication to treat headaches. After your pain reliever wears off, you can experience a withdrawal reaction, which causes you to take more medication, which leads to another headache and a vicious cycle. Eventually you suffer from chronic, daily headaches, with increasing frequency and pain.

The cause for these rebound headaches is frequent use of any type of pain reliever, including OTC Tylenol, Advil, Excedrin; or prescription-strength drugs, like Imitrex, Fiorinal, or Tylenol with Codeine No. 3. How quickly you develop a rebound headache disorder depends on your usage and the medication itself. Everyday doses of caffeine (from coffee or soda or other products you consume) may also contribute to rebound headaches.

Your symptoms may differ depending on the type of original headache you had and the specific medication you used. In general, rebound headaches:

  • Occur every day or almost every day, usually waking you in the early morning; and
  • Improve with pain relief medication, but return as the medication wears off.

Other symptoms may include:

  • Nausea;
  • Listlessness;
  • Restlessness and difficulty concentrating;
  • Memory problems; and
  • Irritability.

Some risk factors for rebound headaches are a history of chronic headaches and frequent use of headache medications.

Prevention & treatment

To prevent rebound headaches, you should:

  • Always follow the label instructions on your medications and the advice of your healthcare provider;
  • Only use pain-relieving medications on a limited basis, when it’s necessary. Take the smallest dose needed to relieve your pain. Don’t use them more than once or twice a week, unless your healthcare provider instructs you otherwise;
  • Ask your healthcare provider about any potential drug interactions before taking any OTC medications, including common pain relievers and antihistamines; and
  • Avoid caffeine-containing products while taking pain-relieving medications, especially if they already contain caffeine.

To treat your rebound headaches, you will need to break the cycle and restrict your pain medication. Your doctor may recommend stopping right away or gradually tapering the dose, depending on the drug. When you stop the medication, your headaches will get worse before they get better and you may even experience withdrawal-like symptoms (nervousness, restlessness, nausea, vomiting, insomnia, or constipation). Your symptoms usually will last two to 10 days, but could last for several weeks.

During this time, you and your healthcare provider may decide it’s best for you to be in a controlled environment and stay for a short while in a hospital.

Once you’ve broken the rebound-headache cycle, you will need to work with your healthcare provider to find a daily, preventive medication to manage your headaches without risking future rebound headaches.

About the Author

Julie Kaplan, Pharm. D.
Julie Kaplan is a licensed pharmacist in Virginia and the District of Columbia. She received a Bachelor’s of Arts in English from The College of William and Mary and a Doctor of Pharmacy from Virginia Commonwealth University. She has experience in patient communication from working as a retail pharmacist.