This is the biggest list of causes you will find for headache on top of the head (writes Dr Raeburn Forbes, Consultant Neurologist).
Most people with pain on top of the head have ‘Tension-type headache’.
However, recent research suggest that this type of pain will often start from the joints, muscles and ligaments of the neck, in which case treating the neck will help.
If Headache on Top of the head is provoked by exertion or changes in posture, you should try to find an explanation.
Common Causes of “Headache Top of Head”
Surveys show that about 20% of adults report the top of the head as the location of Tension-type headache.In children, especially boys for some reason, top of head is also a common, location.Tension-type headache is a featureless pressure or weight in the head with no provoking features such as worsening with physical activity. It does not sit on one side more than another.
About 38% of people in any given year experience one bout of Tension-headache. Severity of Tension-headache is mild-moderate, unlike migraine which is more severe.
This has to be the most common cause of “headache top of head” as 20% of 38% is 7.6% of the population!
Chronic Daily Headache
One 1992 survey before the current IHS crteria for chronic migraine and chronic tension-type headache had been settled, found 32% of people with otherwise unexplained daily headache reporting the top of head (vertex) as a location for headache.
Chronic Daily Headache affects 4-5% of adults, so about 1.3% of the population will experience this cause of “headache top of head”
20% of people with migraine headache will report it as a “Headache top of head”.However they are different from tension-type headache as nausea, preference for dark, worsening with usual physical activity will be present.People with migraine will commonly feel their headaches in other parts of the head too.
If migraine is the cause of a top of head pain, then it is likely that there have been pains elsewhere from time to time.12% of the population (6% of men and 18% of women) experience migraine. So about 2.4% of people will experience a headache on top of the head due to migraine at some point in their lives.
Migraine pain can be dreadful, and if you are having problems with Migraine I recommend that you read about the steps you must take to get back in control. The easiest way to get this information is to sign up for The Headache Friendly Lifestyle – a free email course.
Idiopathic Stabbing Headache
In one large Korean Headache Clinic where these cases were carefully recorded, 10% of 115 cases experienced these intense sudden, brief sharp pains (of no serious causes) in the vertex or top of the head.
Repeated intense cases can be treated with Indomethacin.
Stabbing pains are more common in people with a history of migraine headaches too.However, this must be one of the most common causes of a brief pains on top of the head.
Cold-stimulus Headache or Ice-cream Headache or Brain Freeze
About 8% of the general population are liable to get brain freeze headaches.
In one survey, 12% of adolescents experienced their brain freeze headache on the top of the head.Another study looking at ice-cream headache in people with migraine found that 2 out of 17 people with migraine who experienced ice-cream headache said it was located on top of the head.
Strictly speaking the pain of cervicogenic headache is unilateral – one side only. However, maps of pain relieved by lateral atlanto-axial joint injection show that a “headache on top of the head” affecting both sides can originate from the cervical spine (the lateral atlanto-axial joints).
The lateral atlanto-axial joint is the second most common joint causing cervicogenic headache after the C2/3 facet joint.
As pain on top of the head can be referred from the neck, you should consider an assessment with a specialist physiotherapist if pain on top of the head has been a problem for you.
Causes of a Provoked “Headache Top of Head”
Provoked headaches include those due to low pressure inside the head, and those brought on by exertion.
Post Lumbar Puncture Headache
A low pressure headache follows between 10-50% of lumbar puncture procedures. About 21% of post-lumbar puncture headaches are a “headache top of head”!
The pain of low pressure headache is relieved within seconds to minutes of lying completely flat. It returns within seconds to minutes of standing back up. This phenomenon is called a Postural Headache.
Most of these resolve within 6 days, but any that are severe and persistent will require an epidural blood latch to fix, especially if they are functionally disabling.
Spontaneous Intracranial Hypotension
This is a rare cause of new onset postural headache and probably occurs in at least 5 per 100,000 people per year.
Headache on top of the head is a common feature, as is a pain on both sides of the head.There is often tinnitus, nausea or dizziness. Some people describe the pain like their “brain is falling down a waterfall”.
The headache settles on lying flat, and resumes on standing up again – usually it takes between 15-30 minutes for pain to resolve, but in some it can be nearly instantaneous.
People with spontaneous intracranial hypotension will often remember the precise day, if not hour, of onset of their headaches.
Untreated this can cause years of daily headache – often in the “second half of the day”.
The usual cause is a leak of spinal fluid from a tiny tear in the lining of the spine called a nerve root diverticulum.
Treatment of choice is an epidural blood patch which can be curative, even after months and months of headache.
Pain on the vertex is fairly common in this headache provoked by coughing. In one series of 83 cases, 74 had no obvious cause for their cough headache, and of these 15/74 (20%) experienced a “headache top of head”. 9 cases had a cause identified, and 2 of these 9 (22%) had pain on top of their head.
Cough Headache requires a brain scan to rule out a secondary cause such as Chiari malformation.
These are headaches brought on by exertion, or starting immediately after exercise. A large study of teenagers found that 13% of exercise induced headaches were located on the top of the head.
About 90% of exercise headaches have no known cause. Again Chiari malformation is the most common cause seen on brain imaging.
This is a rare headache (about 1% of headache clinic attenders) and is brought on by sleep. The usual story is someone in their 50-70s who is woken every night at about the same time with a diffuse head pain. One published paper found 1/22 (5%) with a top of head pain only.
Lithium Carbonate 200mg to 400mg at night can help about 70% of cases. Lithium Carbonate is a strong prescription only medication that requires medical supervision to use. I have completed the largest ever online survey of people with Hypnic Headache – the results are interesting!
Heart Disease (cardiac) can cause headaches (cephalalgia). Six of the 32 cases (19%) reported in the medical literature, had pain on top of the head.The headache is usually brought on by exertion and relieved by rest – angina pain in the head.
Acute heart attack pain can present as a thunderclap headache, so an ECG should always be performed in people with thunderclap headache.Treating the heart disease treats the headache.
Sexual Activity Headache
Two types of headache occur with sexual activity (intercourse or masturbation). The first is a slow build up of headache as sexual excitement increases. The more common headache is a sudden explosive headache (thunderclap headache) at orgasm.
It is now known that most orgasmic headaches are due to reversible cerebral vasoconstriction syndrome. 32% (9/28) in one series reported pain in the vertex (top of head).
Bath related Thunderclap Headache
These are sudden severe headaches brought on by immersion in hot water. Many of these are also likely to be due to reversible cerebral vasoconstriction syndrome. Similar to sexual activity headache, 33% (7/22) in one series had pain on top of the head.
Headache after Acoustic Neuroma Surgery
An acoustic neuroma is a rare benign tumour of the main hearing nerve. Surgery for this tumour is usually lengthy and very delicate to perform.
Headache can be a common chronic problem after acoustic neuroma surgery and a 1993 series reported a 34% rate of pain on top of the head, although a more recent study did not find any cases of pain in that location.
Sleep Deprivation Headache
People who are sleep deprived eg doctors doing long on call shifts, can often experience a headache as tiredness increases.5/25 (20%) of people interviewed about sleep deprivation reported a pain on the top of their heads.
10% of people (usually women) who tie their hair in pony tails will sometimes experience pain on top of the head related to traction from the pony-tail. There is an obvious solution – let your hair down!
Chiari Malformation causing Laughter Headaches
Laughter induced headaches are usually due to the Chiari malformation.Usually the pain is in the back of the head. There is one case of pain on top of the head provoked by laughter ad subsequently found to be caused by Chiari malformation
Reversible Cerebral Vasoconstriction Syndrome
This condition can be unprovoked and just cause an out-of-the-blue sudden severe headache – Thunderclap headache. There are cases described with pain on top of the head, not in the classical occipital location
Classically cluster headache is in or around the eye, and associated with tears, nasal symptoms and agitation lasting about 30-180 minutes.
One series from Taiwan found that 22% of 104 cases had pain on top of the head.Other series quoted figures of 3.5% (553 cases) and 7% (230 cases).
The pattern of bouts of intense pain on a daily basis for several weeks, with associated features should give away this diagnosis.
9% of 43 cases reported from London in 2007 has top of head pain.
SUNCT stands for Sudden, Unilateral, Neuralgiform headache with Conjunctival injection and Tears. It is notoriously difficult to treat, but Lamotrigine is often recommended. Fortunately it is really rare.
Isolated Sphenoid Sinusitis
61/72 (85%) cases of isolated sphenoid sinusitis reported headache. Of these 61, 20 (33%) reported pain in the top of head.
This was the most common site of pain in isolated sphenoid sinusitis.11/86 cases had a chronic headache and no other features. The pain of sphenoid sinusitis is often severe, unremitting and worse when lying or with exertion. Classic sinus symptoms like runny nose or nasal congestion are usually lacking. Surgical drainage can be curative.
Chronic Headache Following Whiplash Injury
The definition of headaches following whiplash is fraught with difficulties. There is controversy about how headache referred from neck joints are defined. Most commonly, pain following to trauma to a facet joint of the cervical spine should be one sided. In one series of people with chronic headache preceded by whiplash injury the pain was reported on top of the head in 7% of cases.
Airflight headache with chronic rhinosinusitis
One case of a pain into the vertex which was provoked by air travel and cured when chronic sinus infection was treated.Other cases of airflight headache usually report pain in the eye or above the eye and not on top of the head
Causes of “Headache Top of Head” (not triggered by a provoking stimulus)
These are all unprovoked by physical stimulus or change in environment, and are usually reported as isolated cases – so they are all fairly rare.
Pituitary tumous are often associated with headache.In one series of 84 tumours, headaches were located in the top of the head in 26 (31%).
One case of pituitary apoplexy presented with a thunderclap headache followed by an enduring “headache top of head”
The classic location for nummular headache is on the side of the head – temple or parietal areas. There are published cases of pain on the top of the head – at the vertex. Some of thee cases will have hair loss at the site of pain.
The site of pain in nummular is a well circumscribed area about the size of a large coin. It can be tender, prickly, itchy or burning in quality.A serious underlying cause is not usually found.
Cephalgic Alopecia Areata
One very well characterised case of areas of painful hair loss which was studied using skin biopsy. The patient was treated successfully with botulinum toxin injections, which have also been proposed as a treatment for nummular headache. Disorders of the skin or the scalp are therefore a potential cause of “headache top of head”.
This is usually a condition of people with increased body mass index (obesity). The headache is chronic, daily and non-descript. In one series, 2/58 cases (3%) had pain on top of the head only. The clue to diagnosis from the history is the symptom of pulse-synchronous tinnitus. Incidence of this condition is about 5/100,000 per year, but if detected requires long term follow-up.
Occipital Condyle Syndrome
This condition usually occurs in people known to have cancer. The syndrome is caused by spread of cancer to the base of the skull (the occipital condyle).The nerve to the tongue muscle (hypoglossal nerve) travels just above the occipital condyle. The syndrome causes a headache, which is usually in the back of the head, but can be a cause of “headache top of head” with weakness of the tongue. Tongue weakness causes difficulty speaking or chewing.
Headache in Acute Stroke
About 4% of headaches that accompany acute stroke are located in the top of the head. Always remember that a one-sided headache and stroke may indicate arterial dissection.
One case reported in 2009 found a case of secondary syphilis associated with pain which was located in the top of the head. Headache resolved when treated with penicillin.
Eagle’s syndrome describes pain in the throat, neck or head thought to be due to elongated styloid processes causing irritation to the carotid artery. One case describes exertional headache on the top and side of the head that was releived when a 55mm styloid process was removed.
Another isolated case of pain on top of the head, found to be due to the very rare entity of one-sided hydrocephalus. It was relieved by a ventriculostomy procedure.
Thrombotic Thrombocytopenia Purpura
This usually presents with headache and focal neurology. There can be evidence of internal of external bleeding. Pain is described radiating to the top of the head in at least one case. This is a very rare condition too.
This usually presents as a spinal cord compression, but can cause focal problems in the skull. 6 cases from Taiwan had headache, one of whom had “headache top of head”.
The condition usually responds to steroids, but can mimic carcinomatous meningitis, tuberculosis or Lyme Disease
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