Primary headaches, such as migraine, tension, and cluster (a form of trigeminal, autonomic, and cephalgia) headaches, are usually recurrent or chronic. Secondary headaches include those secondary to stroke, tumor, infection, rarely sinusitis, fever, and other serious conditions that tend to be constant. About 80% of Americans experience some form of headache each year. Fifty percent of these patients have severe headaches, and 10% to 20% consult a physician with headache as the chief complaint. The most common type of headache is the muscle contraction, or tension-type, headache. About 10% of the population has vascular headaches. Headaches caused by acute sinusitis are also fairly common. Less common causes of headaches include glaucoma, short-term use of medications (nitrates, vasodilators, sildenafil) and medication overuse (long-term administration or the sudden withdrawal of analgesics, triptans, and ergot derivatives), temporal arteritis (more common in elderly patients), cervical arthritis, temporomandibular joint (TMJ) dysfunction, and trigeminal neuralgia.
Eye strain and hypertension are uncommon causes of headaches. Most patients with hypertension do not have headaches, and most patients with headaches do not have hypertension. When headaches and hypertension coexist, the headaches are usually not related to the hypertension.
To establish a correct diagnosis, the physician must first differentiate acute headaches from recurrent and chronic headaches. Most common headaches are recurrent; and a few are chronic. Acute headaches are often the most serious (subarachnoid hemorrhage, transient ischemic attack, and thunderclap headache). Acute, recurrent headaches are usually due to migraine. The physician should first elicit the temporal profile of the particular headache and a history of prior headaches. The examiner must ask any patient who complains of headaches about the number and types of headaches, age and circumstances at the time the headaches began, any family history of headaches, the character of the pain (e.g., location of pain, frequency of attacks, duration of headache, time of onset of attack), any prodromal symptoms, associated symptoms, precipitating factors, emotional factors, previous medical history (especially past illnesses, concurrent disease, recent trauma or surgery), allergies, and responses to medication.
An organic disorder should be suspected if the patient has an isolated, severe headache; consistently localized head pain that prevents sleep; headaches associated with straining; headaches accompanied by neurologic signs or symptoms; a change in usual headache pattern; or a chronic, progressively severe headache.
Tension headaches, vascular headaches (including migraine), and headaches due to temporal arteritis are significantly more common in women, as are pseudotumor cerebri and subarachnoid hemorrhage. Cluster headaches are much more common in men (male-to-female ratio, 9:1).
In children as well as adults, the most common type of headache is due to tension or muscle contraction. These headaches are usually of psychogenic origin and are often induced by situational (home, family, school, or work) problems. Although most children with tension headaches may be suffering from simple anxiety or stress, the headache may also be a manifestation of depression, particularly if it is associated with mood change, withdrawal disturbances, aggressive behavior, loss of energy, self-deprecation, or weight loss. If a headache has been present continuously for 4 weeks in the absence of neurologic signs, it is probably psychogenic in origin. Migraine headaches are recurrent.
Studies of young children with chronic headaches have revealed that only a small fraction had an organic cause. In children and adolescents, organic headaches are caused most often by non–central nervous system infections, fever, trauma, and migraine. In children, acute headaches may be the presenting symptoms of a febrile illness such as pharyngitis or otitis media.
Children up to age 7 years have a 1.4% incidence of migraine; among patients aged 17 years, the incidence is 5%. Migraine headaches in young children are usually bilateral and of short duration, and associated symptoms are infrequent. Population studies indicate a 12% incidence of migraine in postpubescent males and up to a 20% incidence in postpubescent females. Despite these studies, the physician must realize that 20% of all adults who experience migraine headaches have onset of symptoms before age 5, and 50% have onset of migraine symptoms before age 20. Although combination headaches (tension and migraine) are common in adults, they are rare in children and their frequency increases with adolescence. Cluster headaches are also rare in children.
Sinus headaches are uncommon in children, but they may occur in young patients, particularly in association with persistent rhinorrhea, cough, otitis media, or allergies. The maxillary sinus is most frequently involved in children. Likewise, headaches of ocular origin are uncommon in children, although the possibility of astigmatism, strabismus, or refractive error must be considered. This possibility is particularly important if the headaches appear to be related to reading or schoolwork or if they occur late in the afternoon or evening.
Increased intracranial pressure should be suspected if a child who complains of headache has other signs of neurologic dysfunction or projectile vomiting without nausea or if the headache is precipitated or exacerbated by coughing or straining. Causes of increased intracranial pressure in children include tumors (headache usually progressive and chronic), pseudotumor cerebri, hydrocephalus (detected by serial head measurements), subdural hematoma (more common in battered children or after trauma), and brain abscess (which may be a complication of otitis media). Malingering can be the cause of headaches in children as well as adults.
In classic migraine (migraine with aura) the aura and prodrome are prominent, and the headaches are throbbing and unilateral. The patient often goes to sleep and, on awakening, frequently finds that the headache has disappeared. Common migraine (migraine without aura) occurs more frequently than classic migraine. In common migraine the aura may be vague or absent. The prodrome may be vague and manifested only by personality change or malaise, nausea, and vomiting. Common migraine headaches are less often unilateral than classic migraine headaches.
Cluster headaches are extremely rare in children, although they may occur in teenagers. Cluster headaches have their highest frequency in the fourth to sixth decades of life. A family history of vascular, sinus, or sick headaches is present in most patients with migraine. A positive family history is not usually present in patients with cluster headaches. Most patients with vascular headaches have a history of headaches caused either by tension or vascular problems. Prior diagnoses may be incorrect because of an inadequate or incomplete history.
Because the incidence of significant disease causing headaches increases with age, the onset of headaches in patients after age 50 years requires careful evaluation and differential diagnosis. Fewer than 2% of patients older than 55 years experience new, severe headaches. If patients older than 55 years have an acute onset of an unrelenting headache that lasts for hours or days, significant disease such as tumor, meningitis, encephalitis, or temporal arteritis should be suspected. Headache may precede the onset of a neurologic deficit. Occasionally, a sudden, new onset of headaches in elderly people strongly suggests cerebral ischemia and impending stroke as well as arteritis.
In patients older than 50 years, only a few conditions cause chronic, severe headaches; they are temporal arteritis, cluster headaches, mass lesions, post-traumatic headaches, cervical arthritis, Parkinson’s disease, medications, and depression. Depression is a common cause of chronic headache in patients older than 50 years, but these patients usually experienced chronic headaches before age 50 as well. Although it is uncommon, temporal arteritis occurs more frequently in elderly women; it should be suspected in elderly patients older than 60 years who have unilateral chronic head pain, unexplained low-grade fever, proximal myalgia, a greatly elevated erythrocyte sedimentation rate (ESR), or an unexplained decrease in visual acuity.
Other, less common causes of headache in elderly patients are congestive heart failure, glaucoma, trigeminal neuralgia, and TMJ dysfunction. Iritis, cerebrovascular insufficiency, cerebral hemorrhage, subdural hematoma, and meningitis are even less common but more serious causes of chronic headache.
The time of onset may be a helpful clue to diagnosis. A headache that awakens the patient suggests headaches of sudden onset, such as a subarachnoid hemorrhage. Morning headache suggests increased intracranial pressure. Other causes of morning (awakening) headaches include medication overuse, depression, carbon monoxide exposure, epilepsy, and, occasionally, migraine. Tension headaches occur in the late afternoon.
The type, severity, and location of pain are important in the differentiation of the cause of headaches (Tables 17-1 to 17-3). Tension (muscle contraction) headaches are usually dull, not throbbing, steady, and of moderate but persistent intensity. If a patient with chronic tension headaches awakens with a headache, its severity may increase as the day progresses and then decrease toward evening. The pain of migraine headaches is severe, initially throbbing, and, later, boring. The severity of this pain increases rapidly and steadily. The pain of cluster headaches is much more severe and more stabbing and burning in quality than that of the usual vascular or tension headaches. The pain of acute sinus headache is usually described as severe, throbbing, and pressure-like. It may be unilateral, often located in the frontal ethmoid or suborbital region.
|AREA OF PAIN||POSSIBLE CAUSE|
|Arteriosclerosis or anemia|
|Central nervous system tumor|
|Head trauma or chronic subdural hematoma|
|Systemic: uremia, thyrotoxicosis|
|Frontal ethmoid sinusitis|
|Midfacial||Dental disease, maxillary sinusitis, nasal disease|
|Ocular or vascular disease, tumor|
|Neurologic (cranial nerve) or vascular degenerative disease|
|Temporomandibular joint disorders, myofascial disease|
|Vascular: arteritis, migraine, cluster headache|
|Facial or ear||Pharyngeal disease (referred pain)|
|Otologic or dental disease; Ramsay Hunt syndrome|
|Vertex||Sphenoid or ethmoid disease|
|Central nervous system, nasopharyngeal neoplasm|
From Schramm VL: A guide to diagnosing and treating facial pain and headache. Geriatrics 35:78-90, 1980.