Types of Headaches

Many individuals have more than one type of headache. It is valuable to establish this information at the beginning of the interview so each type of pain can be carefully delineated. A change in an established headache pattern can indicate a new condition.

Onset of Headaches

A stable headache disorder of many years’ duration is almost always of benign origin. Migraine headaches often begin in childhood, adolescence, or early adulthood. A headache of recent onset obviously has many possible causes, including the new onset of either a benign or serious condition. “Recent onset” has been defined differently by various authors; the typical range is from 1 to 12 months. In general, the more recent the onset, the more worrisome. The “worst ever” headache, an increasingly severe headache, or change for the worse in an existing headache pattern all raise the possibility of an intracranial lesion. Headaches of instantaneous onset suggest an intracranial hemorrhage, usually in the subarachnoid space, but also can be caused by intracerebral hemorrhage, cerebral venous thrombosis, arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, benign angiopathy of the central nervous system (CNS), acute hypertensive crisis, and idiopathic primary thunderclap headache (Ju and Schwedt, 2010). Onset of a new headache in patients older than 50 years raises suspicion of an intracranial lesion (e.g., subdural hematoma) or giant cell (temporal or cranial) arteritis (GCA). A history of antecedent head or neck injury should be sought; even a relatively minor injury can be associated with subsequent development of epidural, subdural, subarachnoid, or intraparenchymal hemorrhage and posttraumatic dissection of the carotid or vertebral arteries (Dziewas et al., 2003). However, posttraumatic headaches can occur following head injury in the absence of any significant pathology.

Frequency and Periodicity of Episodic Headaches

Migraine may be episodic or chronic. Chronic migraine, occurring 15 or more days per month, usually develops in individuals with a history of episodic migraine headaches. Episodic migraine may become chronic with or without medication overuse.

Episodic cluster headaches typically occur daily for several weeks or months and are followed by a lengthy headache-free interval. Chronic cluster headaches occur at least every other day for more than 1 year. If there is no regular periodicity, it is useful to inquire about the longest and shortest periods of freedom between headaches. Having the patient monitor headache frequency, duration, intensity, triggers, and medication use on a headache calendar or in a diary is helpful in diagnosis and measuring response to treatment.

Temporal Profile

A chronic daily headache without migrainous or autonomic features is likely to be a chronic tension-type headache. Untreated migraine pain usually peaks within 1 to 2 hours of onset and lasts 4 to 72 hours. Cluster headache is typically maximal immediately (if the patient awakens with the headache in progress) or peaks within minutes (if it begins while awake). Cluster headaches can last 15 to 180 minutes (usually 45 to 120 minutes). Headaches similar to cluster but lasting only 2 to 30 minutes and occurring several times a day are typical of episodic or chronic paroxysmal hemicrania, both of which are more common in women and are prevented by indomethacin (Goadsby et al., 2010). Primary stabbing headaches (“ice-pick pains”) are momentary, lasting only seconds. Stabbing pains are more common in patients with migraine and cluster headaches. Tension-type headaches commonly build up over hours and last hours to days to years. Headache that is daily and unremitting from onset, usually in patients without prior headaches, is classified as new daily-persistent headache and may have features suggestive of migraine or tension-type headache. A chronic, continuous, unilateral headache of moderate severity with superimposed attacks of more intense pain, associated with autonomic features, suggests the diagnosis of hemicrania continua, an indomethacin-responsive syndrome. Occipital neuralgia and trigeminal neuralgia manifest as brief shocklike pains, often triggered by stimulation in the territory served by the affected nerve. Occasionally a dull pain in the same nerve distribution persists longer, often after a series of brief, sharp pains. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a rare syndrome consisting of paroxysms of first-division trigeminal nerve pain, lasting 5 to 240 seconds but occurring 3 to 200 times per day with the associated autonomic symptoms for which it is named (Goadsby et al., 2010)

Time of Day and Precipitating Factors

Cluster headaches often awaken patients from a sound sleep and may occur at the same time each day in an individual person. Hypnic headaches typically affect older patients and regularly awaken the patient at a particular time of night. Unlike cluster headaches, they are usually diffuse and not associated with autonomic phenomena (Donnet and Lanteri-Minet, 2009). Migraine headaches can occur at any time but often begin in the morning. A headache of recent onset that disturbs sleep or is worse on waking may be caused by increased intracranial pressure. Tension-type headaches typically are present during much of the day and often are more severe later in the day. Obstructive sleep apnea may be accompanied by the frequent occurrence of headache on awakening, as can medication-overuse headache (“rebound headache”).

Patients with chronic recurrent headaches often recognize factors that trigger an attack. Migraine headaches may be precipitated by bright light, menstruation, weather changes, caffeine withdrawal, fasting, alcohol (particularly beer and wine), sleeping more or less than usual, stress and release from stress, certain foods and food additives, perfume and smoke, and others. Alcohol can trigger a cluster headache within minutes of ingestion. If bending, lifting, coughing, or Valsalva maneuver brings on a headache, an intracranial lesion, especially one involving the posterior fossa, must be considered. Exertional headache and headache associated with sexual activity both are worrisome. Although either can occur as a primary headache disorder unassociated with structural disease or can be associated with migraine, both types can also be due to subarachnoid hemorrhage and arterial dissection, both of which must be excluded with the first occurrence of such headaches. Intermittent headaches that are worsened by sitting or standing and improved by lying down are characteristic of a cerebrospinal fluid (CSF) leak. If there is no history of lumbar puncture, head trauma, or neurosurgical intervention, a spontaneous CSF leak may be the cause (Schievink, 2008). Lancinating face pain triggered by facial or intraoral stimuli occurs with trigeminal neuralgia. Glossopharyngeal neuralgia typically is triggered by chewing, swallowing, or talking, although cutaneous trigger zones in and about the ear are occasionally present.