Types of Headaches and How To Treat Them

• Most people will experience a headache at some point in their life.
• There are a variety of headaches, the most common being tension headaches, migraines, and cluster headaches.
• Treatment includes acute pain management options or others which target the headache causes.

A “headache” describes a variety of conditions that cause pain or discomfort in the head or surrounding areas. This can vary greatly, from mild to severe, and may be described as throbbing, dull, squeezing, or sharp.

The causes of headaches are diverse, and many have no identifiable origin. The exact mechanism behind headache pain is often unclear, as the skull and brain do not have any nerves that can register pain. Instead, the pain stems from the tissues surrounding the head and neck.

Various treatment options are available to manage headaches, each targeting different aspects of the condition:

• Pain killers
• Headache specific treatments
• Prevention medication

Types of Headaches

Headaches can be divided into two groups:

• Primary (occurring on their own)
• Secondary (occurring as a result of another situation, medication, or medical condition)

Primary Headaches

Primary headaches do not have specific causes and occur “idiopathically” (without a known cause), though they can be triggered under certain circumstances such as stress, drinking alcohol, or difficulty sleeping.

• Tension Headaches
• Migraines
• Cluster Headaches.

Tension Headaches

Tension headaches are the most common type of primary headache. They typically cause mild to moderate pain, often described as a constant pressure or squeezing sensation in the head, face, and/or neck.

Symptoms

• Pain usually develops gradually and affects both sides of the head.
• Pain may come and go or remain present anywhere from 30 minutes to 7 days.
• More common in younger individuals, women, and people with a history of migraines.

Possible Causes

• While muscle tension was previously considered the main cause, recent evidence suggests that changes in brain hormone levels may also play a role.
• Triggers: Stress (physical or emotional), mental health concerns, poor posture (sitting or sleeping), overexertion/fatigue, and injury/illness.

The main treatment for tension headaches are certain painkillers, which work for acute pain management.

Migraines

Migraines are less common than tension headaches but significantly more painful. The exact cause remains unclear, but it's believed to involve changes in blood flow and nerve activity within the brain.

Characteristics

• More common in women and have a strong genetic component (up to 70% of individuals with migraines have a family history).
• Typically present on one side of the head with moderate to severe pulsing or throbbing pain, often near the eye.
• Associated with nausea, vomiting, and sensitivity to light and noise.
• Episodes can last from several hours to days.
• Some individuals may experience an "aura" before the headache, which can include visual disturbances like wavy lines, halos, or temporary vision loss.

Triggers

A range of medications are available for both treating acute migraine attacks and preventing future episodes.

• While many migraines occur without a clear cause, potential triggers include lack of sleep, specific foods/drinks (alcohol, chocolate, aged cheese), and changes in weather/humidity.
• Triggers vary from person to person and can be identified and managed over time.

Treatment

• Acute treatment medications provide pain relief during an attack.
• Preventive medications are taken daily to reduce the frequency and severity of migraines in individuals who experience them frequently.

Cluster Headaches

Cluster headaches are rare but extremely severe headaches that occur in a series or "cluster" over weeks or months.

Characteristics

• Multiple episodes occur daily during a cluster period.
• Clusters may recur annually or every few years.
• More common in middle-aged men with a smoking history.
• Sudden onset with intense pain on one side of the head, lasting 30-60 minutes.
• Often interferes with daily activities (school, work, sleep).
• Associated with other symptoms on the affected side, such as a blocked nose, watery eye, and drooping eyelid.

Treatment

• Inhalation of high-flow oxygen is a unique and often effective treatment for stopping cluster headaches.
• Various medications are available for treating acute attacks and preventing future clusters.

Secondary Causes of Headaches

Secondary headaches have clear causes and can be managed by resolving the cause. The most common secondary causes of headaches include:

Caffeine Withdrawal

• Symptoms: Throbbing or pulsating pain on both sides of the head.
• Cause: Occurs after 24 hours of reduced or absent caffeine intake.
• Management: Minimize caffeine consumption or consume it consistently at the same time each day.

Medication Overuse

• Cause: Frequent use of pain relief medications can paradoxically lead to headaches.
• Management: Gradually reduce medication use under the guidance of a healthcare provider.

Allergies

• Symptoms: Often accompanied by watery eyes and nasal congestion.
• Management: Avoid allergens and/or treat allergies with antihistamines.

Dehydration/Hunger

• Symptoms: Headaches may be accompanied by weakness and dizziness.
• Cause: Lack of food or water.
• Management: Prevented and treated by eating and drinking fluids.

Eye Strain

• Symptoms: Mild but frequent headaches near both eyes.
• Management: Correct vision with visual aids and reduce eye strain.

Medication Options

Acetaminophen (OTC and Prescription)

• Use: Mild-moderate headaches. Often used as an add-on for more severe headaches.
• Important: Do not use for more than 15 days per month to avoid rebound headaches ("medication overuse headaches").
• Products:
  • Tylenol (acetaminophen)
  • Excedrin Migraine (acetaminophen, aspirin, caffeine) - Contains aspirin (reduces inflammation) and caffeine (for pain relief and blood flow changes).

NSAIDs (OTC and Prescription)

• Non-steroidal anti-inflammatory drugs (NSAIDs) are a very common medication that have both painkilling and anti-inflammatory properties.
• Use: Pain relief and anti-inflammatory properties. Effective for most headache types, including migraines.
• Important: Do not overuse to avoid rebound headaches
• Over-the-counter (OTC): Advil (ibuprofen), Motrin (ibuprofen), Aleve (naproxen)
• Prescription Options (for more severe pain): Celebrex (celecoxib), Cambia (diclofenac)

Triptans

Triptans are often prescribed when typical painkillers have not been sufficient. They have a unique mechanism of action, working on serotonin receptors to result in changes to blood flow and pain signalling in the brain. These medications have largely replaced others for treatment of migraines because they work quickly and have minimal side effects.

• Use: Triptans are a group of medications for acute treatment of migraines. Sumatriptan is approved for cluster headaches and migraines.
• Advantages: Fast-acting, minimal side effects.
• Side Effects: Dizziness, flushing.
• Formulations: Oral tablets, dissolving tablets, nasal sprays, injections.
• Examples:
  • Maxalt (rizatriptan)
  • Naratriptan
  • Zomig (zolmitriptan)
  • Relpax (eletriptan)
  • Amlotriptan (generic)
  • Froza (frovatriptan)
  • Treximet (sumatriptan/naproxen) - Contains naproxen for added pain relief and anti-inflammatory effects.
  • Imitrex (sumatriptan) *Sumatriptan is the only triptan approved for cluster headaches.

Ergot Alkaloids

Similar to triptans, ergot alkaloids are used to treat severe throbbing headaches including migraines and cluster headaches.

• Use: Triptans are a group of medications for acute treatment of migraines. They also work on serotonin receptors to alter the blood flow and block pain signals.
• Disadvantages: More significant side effects than other treatments. Less commonly used now.
• Side Effects: Nausea, vomiting, muscle weakness, chest pain.
• Examples:
  • Maxalt (rizatriptan)
  • Migranal (dihydroergotamine) - Approved for both cluster headaches and migraines.
  • Ergomar (ergotamine) - Approved for migraines.
  • Migergot (ergotamine/caffeine) - Approved for migraines. Contains caffeine for additive effects on blood flow changes.

Reyvow (Lasmiditan)

• Use: Migraine treatment.
• Mechanism: Selective serotonin receptor agonist, similar to triptans but without the blood flow changes.
• Side Effects: Dizziness, drowsiness, tingling/numbness.

CGRP Inhibitors

CGRP inhibitors are medications a class known as “monoclonal antibodies”, with a much different mechanism than most headache medications. CGRP inhibitors are highly effective in the prevention of migraines and are very well tolerated. These medications can be taken as needed for treatment or taken every day for prevention of headaches.

• Use: Migraine prevention and treatment, cluster headache prevention.
• Mechanism: Monoclonal antibodies that bind to CGRP molecules or receptors, preventing their effect on blood flow and inflammation.
• Advantages: Effective for migraine prevention, well-tolerated.
• Side Effects: Nausea, drowsiness, dry mouth (rare and usually mild).
• Migraine Prevention:
  • Ajovy (fremanezumab)
  • Qulipta (atogepant)
  • Vyepti (eptinezumab)
  • Aimovig (erenumab)
  • Emgality (galcanezumab)
  • Nurtec (rimegepant)
• Migraine Treatment:
  • Ubrelvy (ubrogepant)
  • Zavzpret (zavegapent)
  • Nurtec (rimegepant)
• Cluster Headache Prevention:
  • Emgality (galcanezumab)

Beta Blockers

Beta blockers have many uses, most often for of heart-related medical conditions. However, due to the involvement of blood flow in the manifestation of migraines, these medications are used for long-term migraine preventions. These medications are prescribed when as-needed treatment is ineffective and/or when migraines occure frequently.

• Use: Long-term migraine prevention (taken daily). Used when as-needed treatment is insufficient or migraines are frequent.
• Side Effects: Tiredness, dizziness, light-headedness.
• Examples: Inderal (propranolol), Timolol (generic)

Anticonvulsants

Anticonvulsants are medications prescribed for the treatment/prevention of seizures. These medications act in multiple ways, altering the activity in certain areas of the brain to prevent migraines. Anticonvulsants are not first-line for migraine prevention and are associated with a number of different side effects.

• Use: Migraine prevention (taken daily). Used when as-needed treatment is inadequate. Not typically first-line due to side effects.
• Mechanism: Alters brain activity.
• Side Effects: Nausea/vomiting, dizziness, tremors, weight gain or loss (varies by medication).
• Examples: Depakote (divalproex), Topamax (topiramate), Valproic acid (generic)

Butalbital-Containing Products

Butalbital functions as a sedative to cause relaxation and drowsiness and works together with various painkillers (aspirin or acetaminophen) and/or caffeine to manage the pain of tension headaches. Barbiturates come with significant risks and are not commonly prescribed group of medications.

• Use: Tension headaches. Butalbital is a barbiturate sedative combined with painkillers (aspirin or acetaminophen) and/or caffeine.
• Disadvantages: Significant risks, not commonly prescribed. Controlled substance in most states due to dependence risk.
• Side Effects: Nausea/vomiting, dizziness, light-headedness, drowsiness, tremors.
• Examples:
  • Allzital (acetaminophen/butalbital)
  • Fioricet (acetaminophen/butalbital/caffeine)
  • Lanorinal (aspirin/butalbital/caffeine)
  • Aspirin/butalbital/caffeine/codeine (generic)
  • Fioricet with Codeine (acetaminophen/butalbital/caffeine/codeine)

Botox

Botox (onabotulinumtoxinA) is a medication containing a toxin used for cosmetic and medical purposes, including the treatment of chronic migraines. Botox is injected into the muscles around the face/head/neck resulting in an interruption in transmission of signals involved in pain.

This treatment is considered quite effective but is generally reserved for situations in which other medication management has not been adequate. While the injection itself may be painful, the treatment generally has few side effects.

Possible but uncommon side effects may include

• Watering eye(s)
• Drooping of the eye(s)
• Drooling

“Dangerous” headaches may also be associated with other symptoms, such as:

• Confusion
• Numbness/tingling
• Vision loss
• Double vision
• Rigid neck

If you experience a headache that feels unusually severe or is accompanied by other unusual symptoms, it is recommended to seek medical advice immediately. Although severe headaches may be hard to differentiate from more serious events, these events can be serious if left untreated.

When to Worry

Most headaches are not dangerous. Rarely an unusual or uncharacteristically severe headache may be caused by a dangerous medical event, such as an aneurysm or a stroke.

How do you know if you should worry about your headache? There are a variety of criteria that may make a headache more suspicious and warrant a visit to your healthcare provider or local emergency department. This may include: