What Is Headache? Types, Causes, and Effective Solutions

What Is a Headache?

Hello, I am Dr. Emre Gecer. Headache (in medical terminology, cephalalgia) is pain felt in any region of the skull. Approximately 50% of the world's population experiences headache at least once in any given year, and headache is one of the leading causes of lost productivity worldwide. The International Headache Society (IHS) classification recognizes more than 200 types of headache.

Although the vast majority of headaches are harmless and treatable, they can occasionally be the first sign of a life-threatening condition. Therefore, recognizing the types of headache, knowing the warning symptoms, and acting appropriately at the right time is critically important.

Primary vs Secondary Headache Distinction

Headaches are divided into two main groups. This distinction is the most critical first step in determining the diagnostic and treatment approach:

Primary Headaches

These are headaches that occur without an underlying structural or systemic disease. The headache itself is the primary condition. They account for more than 90% of all headaches:

• Tension-type headache (most common)
• Migraine
• Cluster headache
• Other primary headaches (stabbing, cough-triggered, exercise-related, etc.)

Secondary Headaches

These are headaches that develop due to another underlying disease. They are less common, but some can be life-threatening:

• Subarachnoid hemorrhage (SAH)
• Meningitis and encephalitis
• Brain tumors
• Temporal arteritis (giant cell arteritis)
• Idiopathic intracranial hypertension (pseudotumor cerebri)
• Cerebral venous sinus thrombosis
• Medication-overuse (rebound) headache
• Sinusitis, glaucoma, cervical pathologies

Tension-Type Headache

The most common type of primary headache. Approximately 40-80% of adults experience tension-type headache at least once in their lives.

Characteristic Features

• Quality of pain: Pressing, squeezing, band-like (bilateral) pain
• Severity: Mild to moderate (does not prevent daily activities)
• Location: Bilateral, forehead, temples, or occipital region
• Duration: 30 minutes to 7 days
• Associated symptoms: Photophobia (light sensitivity) or phonophobia (sound sensitivity) may be present but not both together. Nausea is usually absent.
• Physical activity: Does not worsen the pain (unlike migraine)

Triggers

Stress (most common), irregular sleep, prolonged screen time, poor posture, neck muscle tension, skipping meals, dehydration, and eye strain are the main triggers.

Treatment

Acute treatment: Paracetamol (acetaminophen) 500-1000 mg or ibuprofen 400-600 mg is usually sufficient. Aspirin and naproxen are also effective. Taking medication early, while the pain is still mild, increases its effectiveness.

Prophylaxis (preventive treatment): If tension-type headache occurs on more than 15 days a month (chronic form), preventive treatment is considered. Amitriptyline (10-75 mg/day) is the first-line prophylactic agent.

Migraine

Migraine is a neurovascular disease that affects approximately 1 billion people worldwide and seriously reduces quality of life. It is 3 times more common in women than in men. According to Bradley's Neurology in Clinical Practice, migraine is a complex neurobiological process involving the brainstem and trigeminal nervous system, activated by environmental triggers in individuals with genetic predisposition.

Phases of Migraine

A migraine attack typically consists of four phases, although not every patient experiences all phases:

1. Prodrome Phase (Premonitory Symptoms)

Changes that begin 24-48 hours before the pain: fatigue, irritability, difficulty concentrating, neck stiffness, food cravings (particularly for sweets), frequent urination, and increased yawning. Approximately 60% of patients experience the prodrome phase.

2. Aura Phase

Occurs in approximately 25-30% of migraine patients. These are transient neurologic symptoms that begin 5-60 minutes before the pain:

• Visual aura (most common, ~90%): Bright, shimmering zigzag lines (fortification spectra), dark spots in the visual field (scotoma), flashes of light
• Sensory aura: Numbness or tingling in the face or hand
• Motor aura: Rare; unilateral weakness (hemiplegic migraine)
• Speech aura: Difficulty speaking (aphasia)

Aura symptoms usually last 5-60 minutes and resolve completely. Symptoms lasting longer than 60 minutes, or persistent neurologic deficits, require urgent evaluation.

3. Headache Phase

• Quality of pain: Throbbing, pulsatile character
• Severity: Moderate to severe (prevents daily activities)
• Location: Usually unilateral, but can be bilateral
• Duration: 4-72 hours without treatment
• Aggravating factors: Physical activity, light, sound, smell
• Associated symptoms: Nausea (80%), vomiting (50%), photophobia, phonophobia, osmophobia (sensitivity to smells)

4. Postdrome Phase

After the pain resolves, fatigue, difficulty concentrating, neck stiffness, and depressed mood may last 24-48 hours. Some patients call this the "migraine hangover."

Migraine Triggers

• Stress and the post-stress relaxation period (weekend migraine)
• Hormonal changes (menstrual period, use of oral contraceptives)
• Irregular sleep (too much or too little)
• Skipping meals and hunger
• Certain foods (aged cheese, chocolate, alcohol — particularly red wine, nitrate-containing processed meats)
• Bright lights, strong odors
• Weather changes and pressure differences
• Caffeine withdrawal

Migraine Treatment

Acute treatment:

• For mild attacks: NSAIDs (ibuprofen 400-600 mg, naproxen 500-1000 mg) or paracetamol + caffeine combinations
• For moderate-to-severe attacks: Triptans (sumatriptan 50-100 mg oral, 6 mg subcutaneous) are the gold standard for acute migraine treatment. They act as 5-HT1B/1D receptor agonists.
• Antiemetics: Metoclopramide or domperidone both control nausea and speed gastric emptying, improving absorption of oral medications
• For refractory attacks: Dexamethasone, IV ketorolac, or dihydroergotamine

Prophylactic treatment: Preventive treatment should be started if 4 or more migraine attacks occur per month:

• Beta blockers: Propranolol (40-240 mg/day), metoprolol — first line
• Antiepileptics: Topiramate (25-100 mg/day), valproic acid
• Antidepressants: Amitriptyline (10-75 mg/day), venlafaxine
• CGRP monoclonal antibodies: Erenumab, fremanezumab, galcanezumab — a new and effective class for migraine prophylaxis
• OnabotulinumtoxinA (Botox): Approved for chronic migraine (15+ days/month)

Cluster Headache

The most severe primary headache type; also known as "suicide headache." It is 3-4 times more common in men than in women. According to Adams & Victor's Principles of Neurology, hypothalamic dysfunction plays a central role in its pathophysiology.

Characteristic Features

• Quality of pain: Unilateral, very severe, piercing, burning pain in the orbital/periorbital area
• Duration: 15 minutes to 3 hours
• Frequency: 1-8 attacks per day, usually at the same time each day (especially at night)
• Cluster period: Attack periods lasting 4-12 weeks, followed by silent periods of months to years
• Autonomic features (ipsilateral): Eye redness and tearing, nasal discharge or congestion, eyelid drooping (ptosis), pupil constriction (miosis), forehead sweating
• Agitation: Unlike migraine, the patient cannot stay still and paces around

Treatment

Acute treatment: High-flow (100%) oxygen inhalation (12-15 L/min for 15-20 minutes) and subcutaneous sumatriptan (6 mg) are the most effective acute treatments.

Prophylaxis: Verapamil (240-960 mg/day) is first line. Short-term corticosteroid bridge therapy, lithium, and topiramate are other options.

Medication-Overuse (Rebound) Headache

Using analgesics or triptans on more than 10-15 days per month can paradoxically increase headache frequency. This is one of the most common causes of chronic daily headache. The cornerstone of treatment is the gradual withdrawal of the offending medication and starting appropriate prophylactic therapy. Headache may temporarily worsen during the withdrawal period; the patient must be supported and informed during this time.

Red Flags: When Is Urgent Evaluation Needed?

Neurology uses the mnemonic "SNOOP" to remember warning symptoms in headache:

• S — Systemic symptoms: Fever, weight loss, history of cancer, HIV positivity
• N — Neurologic symptoms: New neurologic deficit (weakness, vision loss, speech disturbance, altered consciousness)
• O — Onset: Sudden-onset (reaching maximum within seconds to minutes) "thunderclap" headache — subarachnoid hemorrhage must be ruled out
• O — Older age: New-onset headache over the age of 50 — temporal arteritis and intracranial pathology must be excluded
• P — Pattern change: A marked change in the existing headache pattern, progressively increasing frequency or severity

Additional alarm features:

• "Worst headache of my life"
• Fever and neck stiffness (suspected meningitis)
• Headache triggered by coughing, straining, or a Valsalva maneuver
• Papilledema (optic disc swelling on fundoscopy)
• New severe headache in pregnancy or the postpartum period
• New headache in an immunosuppressed patient
• New headache while on anticoagulants

When Is Imaging Needed for Headache?

According to Harrison's, routine imaging is not recommended in patients with a typical primary headache history and a normal neurologic examination. However, brain imaging (preferably contrast-enhanced MRI or CT) is indicated in the following situations:

• Presence of any of the red flags listed above
• Abnormal findings on neurologic examination
• Unexplained change in headache pattern
• Sudden-onset severe headache — CT + LP (lumbar puncture)
• Accompanying headache in a patient with a first-time seizure

Lifestyle Changes and Prevention

Lifestyle modifications are as important as drug treatment in headache management:

• Regular sleep: Go to bed and wake up at the same time every day; aim for 7-8 hours of sleep
• Regular meals: Do not skip meals; maintain blood sugar balance
• Regular exercise: At least 150 minutes of aerobic exercise per week reduces migraine frequency
• Stress management: Meditation, progressive muscle relaxation, cognitive behavioral therapy
• Adequate hydration: Dehydration is a common headache trigger
• Trigger diary: Identify your personal triggers by keeping a headache diary
• Ergonomic adjustments: Screen distance, lighting, working posture
• Limit caffeine intake: Do not exceed 200 mg/day (about 2 cups of coffee); sudden withdrawal can also trigger headache

Conclusion

Headache is a common complaint that is mostly harmless and treatable. Tension-type headache and migraine are the most frequent types and can be controlled with appropriate treatment. However, in the presence of alarm symptoms such as sudden severe headache, headache with neurologic signs, or a change in pattern, I strongly recommend obtaining medical evaluation without delay.

Wishing you healthy days.
Dr. Emre Gecer

References

• Harrison's Principles of Internal Medicine, 22nd Edition — Chapter: Headache
• Adams and Victor's Principles of Neurology, 12th Edition
• Bradley and Daroff's Neurology in Clinical Practice, 8th Edition
• International Classification of Headache Disorders, 3rd Edition (ICHD-3)
• Ashina M, et al. Migraine. N Engl J Med. 2020;383:1866-1876