Migraine headaches are periodic, throbbing headaches; usually unilateral, and over one eye or in the temple. Sensitivity to sound (phonophobia) and light (photophobia) is common, as are nausea and vomiting. Scalp sensitivity is also common. Neurologic symptoms may precede the headache (migraine with aura), or the headache may occur alone (migraine without aura). There is often a family history of migraine. Sometimes that patient has a history of motion sickness. Symptoms often begin during teenage years. Migraine is more common in females.

Cluster headaches are sharp, knife-like, and unilateral, and often are over one eye. They are more common in males, and begin later in life than do migraine headaches.

Tension-type headaches tend to be diffuse, steady, non-throbbing headaches in the front or back of the head. They are bilateral, and often described as “band-like,” “pressure,” or “tight” headaches. They occur in all age groups.

Migraine headaches are periodic, lasting a few hours to a few days. They may occur at any time and may awaken the patient from sleep. They often begin during a “relaxed” time (e.g., the weekend). Status migrainosus refers to migraine that lasts for days.

Cluster headaches come in groups over a few weeks or months (a cluster), and then subside. They last for a few minutes to 1 to 2 hours and tend to occur at the same time every day. They may awaken the patient 1 or 2 hours after falling asleep.

Tension-type headaches usually last hours, but may last days, weeks, and even months. They frequently occur at the end of a stressful day.

Migraine may be exacerbated or relieved during menstruation or pregnancy or at the time of menopause. Migraine is often relieved by sleep, or after vomiting. Migraine may be brought on by hunger, alcohol ingestion, caffeine withdrawal, and certain foods such as aged cheese, cured meats, and chocolate. The use of birth control pills may worsen migraine.

Cluster headaches are often precipitated by alcohol, sometimes exquisitely so. Cluster headaches are not relieved by environmental factors until they have run their course.

Tension-type headaches may be relieved with relaxation, neck massage, or rest.

Migraine with aura may be accompanied by a variety of neurologic symptoms, often immediately preceding the headache. These include visual symptoms such as flashing lights, zig-zag lines, blind
spots, or complete loss of a visual field. These last for minutes, and the headache usually begins as the visual symptoms recede. Many other neurologic symptoms can occur. These include visual field loss, difficulty talking, tingling of parts of the body, and even hemiparesis (“hemiplegic migraine”). Confusion, vertigo, stupor, and ataxia are less common but well-documented manifestations of migraine. A key feature that distinguishes migranous neurologic symptoms from stroke is their progression over minutes rather than seconds.

In cluster headaches, tearing, facial flushing, and a stuffy, runny nose are common. These are usually ipsilateral to the headache. Sometimes Horner syndrome may accompany the headache (small pupil, ptosis). These are all features of autonomic dysfunction.

Tension-type headaches lack associated symptoms.

Occasionally, a patient presenting with a new or changed headache is harboring a major illness that requires diagnosis and treatment. The following symptoms are suggestive of an ominous cause and, if present, require careful evaluation:

Examination sometimes offers clues to the type of headache or to the presence of organic causes, especially if the patient is symptomatic during the examination.