Pain-Free Living

All Headaches Are Not Created Equal

By Robert Dinsmoor

Most people have headaches at some point in their lives. Doctors have identified 200 different types of headaches, and the proper treatment depends on which type you have. Most headaches are relatively harmless, but some can be debilitating or may point to serious or even life-threatening underlying conditions. Fortunately, there are several measures you can take to treat the most common headaches, and certain “red flags” can help you recognize when you need immediate medical attention.

The Most Common Types of Headaches

⇒Tension headaches. Tension headaches, also known as myogenic or muscle contraction headaches, are the result of tensing of the facial and neck muscles. Their underlying causes include stress, anxiety, depression, sleep problems and jaw clenching. Typically, the pain is constant and can be located anywhere throughout the head or neck. Sometimes people describe the pain as feeling like a “hatband” or a “vise,” and it can vary widely in frequency, intensity and duration. Tension headaches may occur in reaction to stress or a migraine attack. The most common treatments for tension headaches are rest, stress reduction and over-the-counter pain relievers such as aspirin, acetaminophen (brand name Tylenol), ibuprofen (Advil or Motrin) or naproxen sodium (Aleve).

⇒Migraine headaches. The causes of migraines aren’t completely understood. The traditional view has been that they are caused by the dilation of arteries in the head. However, an emerging alternative hypothesis suggests the problem lies in the nervous system with cranial nerves called the trigeminal nerves, a nervous pain pathway or imbalances in nerve chemicals (neurotransmitters) such as serotonin, which is responsible for regulating pain. Migraine headaches occur more commonly in women than in men and usually begin during childhood, adolescence or early adulthood. They may be triggered by hormonal changes (in women), lack of sleep, lack of food, certain foods or food additives, alcohol, caffeine, stress and sensory stimuli such as bright lights or loud noises.

Migraines typically cause intense pulsing or throbbing pain in one area of the head. They can be accompanied by sensitivity to light or sound, nausea, vomiting and blurred vision. There also may be a prodome, a set of symptoms that occur one or two days before the migraine, including constipation, depression, food cravings, irritability and neck stiffness. In an estimated one-third of migraine sufferers, a set of neurological symptoms called an aura may occur before or during the migraine attack. The aura symptoms may include visual disturbances such as flashes of light, zig-zag patterns or temporary vision loss; a “pins and needles” feeling in the arms or legs; and difficulties with speech or language.

Two broad categories of medicines are used to treat migraines—acute medications to treat migraines already in progress and preventive medications taken regularly to decrease the frequency and severity of migraines. Acute treatments consist of several different types of medication, including painkillers such as acetaminophen, aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen sodium. Triptans, which help constrict blood vessels and block the pathways responsible for pain in the brain, include sumatriptan (Imitrex, Imigran), rizatriptan (Maxalt), almotriptan (Axert, Almogran), naratriptan (Amerge, Naramig), zolmitriptan (Zomig), frovatriptan (Frova, Migard), eletriptan (Relpax) and a combination of sumatriptan and naproxen sodium (Treximet). Most of these medications are in tablet form, but some also are available as nasal sprays or injections.

Ergotamine medications also may be used. They appear to alleviate migraines by constricting blood vessels in the brain, but according to some experts, they are not as effective as Triptans. Ergotamine is combined with caffeine in the products Migerot and Catergot. Ergotamine may worsen the nausea and vomiting associated with migraines. The ergotamine derivative dihydroergotamine (D.H.E. 45, Migranal) may be more effective than ergotamine, with fewer side effects.

Sometimes anti-nausea drugs such as chlorpromazine (Promaper, Thorazine), metoclopramide (Reglan) or prochlorperazine (Compro) are used for migraine-associated nausea. Opioid medications such as codeine sometimes are used to treat headache pain in people who can’t take triptans or ergotamines. Glucocorticoids such as prednisone (Cortan, Deltasone, Orasone, Sterapred) or dexamethasone (Bycadron, DexPak, Zema) sometimes are used in combination with other medications to better relieve pain.

People who have frequent, prolonged or intense migraine attacks or aren’t helped by pain relievers may need preventive medications on a regular basis. Beta blockers, calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors—classes of drugs commonly used to treat high blood pressure and cardiovascular disease—may be used to reduce the frequency and severity of migraines as well. Beta blockers include propranolol (Inderal, Innopran), metoprolol tartrate (Lopressor) and timolol (Betimol). The calcium-channel drug verapamil (Calan, Verelan, Covera, Isoptin) sometimes is used for migraine prevention. The ACE inhibitor lisinopril (Zestril, Prinivil, Tensopril) also may be used to decrease the duration and intensity of migraine headaches.

Antidepressants sometimes are used to prevent migraine headaches. Tricyclic antidepressants such as amitriptyline (Elavil, Endep, Vanatrap) appear to prevent migraines through their effects on serotonin and other neurotransmitters. A serotonin and norepinephrine uptake inhibitor called venlafaxine (Effexor) also appears to be helpful in preventing migraines.

⇒Cluster Headaches. Cluster headaches are severe, debilitating headaches that occur in “clusters”—that is, they occur repeatedly for a period of weeks to months, alternating with periods of being headache-free. The exact cause of cluster headaches is not known, but it involves overactivation of the trigeminal nerves, the largest pair of cranial nerves. They are more common in men than in women. They may be triggered by alcohol, smoking, certain medications and sleep disturbances. Cluster headaches tend to begin quickly, without warning, and peak within minutes. The pain tends to be excruciating and continuous and typically begins around the eye or temple on one side of the face. There may be eye redness and teardrop production on the side of the head with the pain. Like migraines, cluster headaches typically are treated with Triptans, and they may benefit from prednisone, ergotamine or lithium.

⇒Traction and Inflammatory Headaches.Traction headaches are caused by the pulling, stretching or displacement of pain-sensitive parts of the head. One cause of traction headaches may be tensing of the eye muscles to compensate for eye strain, but they may have more serious underlying causes such as brain tumors, strokes and head trauma. Symptoms may vary according to the cause (see Red Flags, below) Traction headaches are treated by addressing the underlying cause.

Inflammatory headaches result from diseases of the sinuses, spine, neck, ears and teeth. They can be caused by a number of diseases, including sinus infections, tooth infections and meningitis. As with traction headaches, the symptoms and treatments depend on the underlying causes. (See Red Flags, below)

One common cause of inflammatory headaches is sinus inflammation (sinusitis), which can cause pain and a sensation of pressure in the face. A sinus headache often is accompanied by other symptoms such as nasal congestion, runny nose and cough. Sinus inflammation can be caused by allergies, the common cold or bacterial infection, all which can cause the sinuses to swell. Acute sinusitis can be treated with over-the-counter decongestants and nasal drops, and antibiotics may be used if it is believed to be the result of an infection. Chronic sinusitis may be treated with steam from a vaporizer or a pan of boiling water, warm compresses and saline nasal drops. If sinusitis is the result of allergies, over-the-counter oral antihistamines such as loratidine (Claritin or Alavert), fexofenadine (Allegra), diphenhydramine (Benadryl), clemastine (Tavist), chlorpheniramine (Chlor-Trimeton) or certirizine (Zyrtec), and antihistamine sprays such as fluticasone (Flonase) and triamcinolone (Nasocort) may help. In rare instances when the sinus openings are narrowed and mucus movement is blocked, surgery may be needed.

Red Flags

Although headaches are common and usually nothing to worry about, they also can be a symptom of a serious underlying condition such as a stroke or meningitis. Call 911 or go to the emergency room immediately if you experience a sudden, severe headache, the worst headache you’ve ever had or a headache accompanied by any of these symptoms.

• Neurological symptoms such as confusion; trouble understanding speech; trouble seeing, speaking or walking; numbness, weakness or paralysis on one side of your body
• Fainting
• High fever
• Stiff neck
• Unexplained nausea or vomiting

These symptoms may indicate such serious conditions as stroke, aneurysm or spinal meningitis.

General Guidelines for Treating Headaches

Most headaches can be treated with rest or over-the-counter pain medications. It is best to get ahead of the pain by taking these medications while the symptoms still are mild. Avoid taking more than the recommended dosage to avoid rebound headaches. If these medications fail to work, talk with your family doctor about other medications he or she can prescribe (many mentioned above).

You also can take lifestyle measures to help prevent headaches. They are beneficial to overall health as well.

• Don’t skip breakfast, because fasting is a common cause of headaches.
• Get enough sleep. Lack of sleep can interfere with your ability to manage stress.
• Exercise regularly. The American College of Sports Medicine recommends getting 30-60 minutes of moderate-intensity exercise five times a week.
• Consider yoga, meditation and relaxation therapy to relieve stress.
• Take a break, from a brief walk to a vacation, to get away from stressful situations.
• Find pleasurable activities, such as playing a sport, listening to music, reading a book or playing with pets.

When headaches do occur, there are nonmedical measures you can take to alleviate the pain.

• Take a hot shower.
• Place a heat pack or an ice pack on your head or neck.
• Massage your temples and the muscles in your neck and shoulders. This can be useful especially for treating tension headaches.

Not all headaches are created equal. They can have a variety of underlying causes and can be accompanied by a variety of symptoms. The more you and your doctor know about your specific type of headache, the better treatment can be tailored to your needs.

Robert S. Dinsmoor is a medical writer and editor based in Massachusetts.

Last Reviewed September 30, 2015

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