Headache Types - which do you have?

There are many different severe headache types.

If you can learn these types of headache you are over a major hurdle before you commit to your diagnosis.

Learning how to make a headache diagnosis is like 3 steps forward and 2 steps back - it can be frustrating. There is no substitute for experience.

You need to learn about the different types of headaches first (3 steps forward), and then start to listen and learn headache histories from your patients/clients.

However, as you listen to these histories, you will hear symptoms or scenarios that you do not know anything about - back to the drawing board - 2 steps back.

This is the classic process of medical education. You read and acquire background knowledge, and combine this with seeing as many people with headache symptoms as you possibly can.

1. Frequency
• First Ever Headache
• Headache Episodes (or Episodic Headache) Constant Headache or Near-constant Headache
• Headache Location
• Back of Head or Occipital Headache
• Pain in the Eye
• Pain in the Face
• Unilateral Headache
• Headache Quality
• Pressure Headache Throbbing Headache
• Short Sharp Pain (neuralgiform) Headaches
• Timing of Headache Onset
• Things that bring on the Headache - Provoking Factors

Like all clinical diagnosis each of these components has to be weighed-up carefully to try and arrive the best-fit diagnosis or differential diagnosis (a differential diagnosis is a shortlist of plausible alternative diagnoses).

Associated clinical features, that you observe in the clinical examination, will sometimes help and occupation is sometimes important.

Some headache types are just strange headaches.

First Ever Headache? or Headache Episodes? or Constant Headache?

First Ever Headache could be thunderclap headache, headache with fever, headache with focal neurology new onset persistent headache or the first episode of what will turn out to be a primary episodic headache disorder like migraine.

Episodic headache has either longer duration (> 4hours per headache) like migraine or tension-type headache, or is made up of much shorter episodes of headache - the neuralgiform headaches (usually seconds or minutes, but no more than 2 hours of pain).

Constant Headaches are usually chronic migraine, chronic tension-type headache or some of the rare secondary headaches like Sphenoid Sinusitis or Intracranial Hypotension.

Headache Location

An occipital headache (pain in the back of the head) suggests a different list of diagnoses to pain in the eye, or pain in the face.

A Global Headache (an all-over headache) or a frontal headache or a temporal headache (side of head) do not accurately predict other headache types, although migraine and tension-type headache remain the most common causes of global, frontal and temporal headache.

Unilateral headaches are restricted to one side of your head only. If your headache only, and exclusively occurs on one side and never crosses over, this is also called a "side-locked headache". Unless you have a definite diagnosis of migraine (about 20% of migraine sufferers will have side-locked headache) a history of strictly unilateral headache can make it useful to have a further evaluation of your headache condition - to exclude underlying structural disease.

Here's a list of causes of Unilateral or Side-locked Headache.

Headache Quality

I would normally take the term pressure headache to equal to tightness, weight, heaviness or band-like.

A throbbing pain, can also be described as pulsing, aching, or splitting by my own patients. Throbbing pain usually means migraine, but again lots of headaches may throb. It is important to distinguish a pulsing noise - which is pulsatile tinnitus - from a throbbing pain - which is..well..a pain!

Very short sharp pain headaches - called neuralgiform pains - which can be associated with autonomic activation (tears, nasal blockage, reddening of the eye, drooping or ptosis of the eyelid). These can be described as stabs, jabs, jolts, shot, stabbing, shooting or piercing.

The quality of the headache is sometimes helpful, especially in primary care, where a pressure headache usually means tension type headache. However, beware carbon monoxide poisoning which can cause persistent pressure type headache, in those with potential Carbon Monoxide exposure.

A throbbing headache, sick headache or pulsing pain in a primary care setting usually means migraine.

How Long from the Start of a Headache until it Gets to its Worst?

This is a good way to distinguish headaches that are true sudden severe, maximal at onset headaches - thunderclap headaches, from those that are also severe by the time they arrive for medical advice. These headaches that build up over minutes or hours are more likely to be migraine.

The distinction is important. You can spare unnecessary investigations like lumbar puncture if you correctly identify a headache as migraine, instead of thunderclap.

Did Anything Bring The Headache On?

Provoked types of headache, on average, have a higher chance of being related to underlying disease.

Cough headache (a headache produced on coughing) has some very specific causes that need investigated, as up to 40% will have structural disease, such as Chiari Malformation.

Exercise headache and sex or orgasm headaches are also situations where underlying pathology needs to be ruled out with investigations.

Some headaches will occur after eating cold food or drink, such as ice cream headache (also called "brain freeze" - the International Headache Society approved term is cold stimulus headache).

Does Anything Else Happen When you get Your Headache?

1. Sensory Sensitivity
• Nausea
• Intolerance of light or preference for dark (photophobia)
• Intolerance of noise or preference for quiet (sonophobia or phonophobia)
• Intolerance of smell (osmophobia)
• Intolerance of movement - preference to lie down
• Vomiting
Sensory Sensitivity is the hallmark of migraine, and at least two of the sensory sensitivity symptoms are present in definite migraine.
2. Autonomic Activation
• Watering of the eye - lacrimation
• Nasal congestion
• Running of the nose - rhinorrhoea
• Drooping of the eyelid - ptosis
• Reddening of the eye - conjunctival injection
• Swelling around the eye
Autonomic activation usually points towards cluster headache, or one of the other headache types like the Trigeminal Autonomic Cephalalgias e.g. SUNCT or Paroxysmal Hemicrania.
3. Other symptoms
• Syncope or loss of consciousness at onset of headache Someone who faints at the onset of a thunderclap headache has an increased risk of subarachnoid haemorrhage.
• Pulsatile Tinnitus may mean raised intracranial pressure such as from Idiopathic Intracranial Hypertension or Cerebral venous SInus Thrombosis
• Difficulty with speech, can occur in migraine
• Difficulty with vision, also can occur in migraine, but Pituitary Apoplexy can present with acute headche and visual disturbance, as can Temporal Arteritis.
• Flashing lights or visual aura - is migraine related in the overwhelming majority of cases.
• Pacing the floor or agitation - occur in association with the severe pain of cluster headache

What examination findings will change your diagnosis?

You should add to Forbes Quick Neurological Examination the following, if your clinical history dictates:

Vital Signs (Temp, BP, RR, Pulse Rate - which are essential in all acute headache cases).

Assess for meningism in acute headache, or if fever present.

Check the eyelid position for Horners Syndrome in eye, face or neck pain or headache with associated weakness or difficulty speaking.

Palpate the head for trigger points, especially over the entry points of the main cutaneous sensory nerves - greater occipital, and supraorbital nerve.

Palpate the temporal and occipital arteries if you may have a case of Temporal Arteritis

If your quick neuro exam did elicit any focal signs you really do need to image to exclude a serious cause for the severe headache.

Is is just a Headache - or is it Headache and Neck Pain?

Is it simply a Strange Headache?