AT A GLANCE: Headaches are one of the most universal human experiences, but they range from minor inconveniences to severely disabling conditions that require medical attention. Here are four things you will learn about headaches from William B. Young, MD, professor of neurology and director of innovation and strategy at the Thomas Jefferson University Headache Center, in this article:
- Headaches fall into two categories: primary headaches—tension-type, migraine and cluster—and secondary headaches caused by an underlying condition such as meningitis or a brain tumor.
- Migraine attacks go beyond head pain, including light, sound and smell sensitivity, nausea and, for up to 30% of patients, an aura that can occur even without a headache.
- Women are about three times more likely as men to experience a migraine, which has been identified as the second leading cause of disabled days in the world.
- Most common trigger lists for migraine are misleading—and eliminating everything on them often does more harm than good.
- If you have a new and unusual headache that does not go away or is accompanied by a neurologic symptom, contact your doctor and get evaluated properly.
While virtually everyone has had one, headaches are far from equal. They range from the occasional tension headache resolved with over-the-counter medication to migraine attacks, which can last up to 72 hours and leave a person unable to work, operate machines, or perform common tasks. And for a small but significant share of the population, cluster headaches strike with a ferocity widely regarded as among the most extreme pain experiences a human being can endure.
But understanding which type of headache a person has is not always straightforward. For most primary headaches, there is no diagnostic test. A physician trained in headache medicine determines whether the pattern of symptoms meets established clinical criteria, a distinction that carries serious implications. Treating a secondary headache caused by a brain tumor or infection as if it’s a tension headache could have serious complications. Undertreating migraine, meanwhile, has well-documented consequences for quality of life and long-term productivity.
The AMA’s What Doctors Want Patients to Know™ series gives physicians a platform to share what they want patients to understand about today’s healthcare headlines and how to take charge of their health through preventive care.
In this installment, William B. Young, MD, professor of neurology and director of innovation and strategy at the Thomas Jefferson University Headache Center, shares how to recognize the warning signs of a medical emergency and why dismissing a migraine as "just a headache" can have lasting consequences.
Jefferson Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Headaches are very common
"A headache is really any kind of pain—and maybe even discomfort—in the head. They're extremely common,” Dr. Young said, noting that “at least 70% of people have tension-type headache.”
“Almost everybody can generate a headache under certain circumstances, such as a hangover,” he said. “It's very rare to find somebody in this world who's never had a headache.”
There are two major types of headaches
"We think about headache as coming in two major types. One is secondary headaches, where there's a cause—like meningitis or a brain tumor,” Dr. Young explained. “And then the more common type is a primary headache, of which the most common is tension-type headache, which occurs in about 70% of people.”
Meanwhile, “about 15% of people in any given year will have migraine attacks,” he said. “Then cluster headache is much less common—perhaps one in a thousand. But it is very different, extremely severe. It's hard not to have it and need to have it treated.”
Migraine attacks are far more than a bad headache
"Most of the primary headache disorders—like migraine and cluster headache—have other symptoms that go with it,” Dr. Young said. “Migraine has light and sound sensitivity, sensitivity to touch, smell sensitivity, nausea for some, and other features besides just the pain.
“Up to 30% of people who have a migraine will have an aura, which is most commonly a visual aura,” he added. “It will precede the headache for about 20 or 30 minutes, and it may occur without even getting a headache. It's still considered to be migraine.”
“From a burden of illness standpoint—how much it takes out of the population—migraine is perhaps the most important headache type,” Dr. Young said. “And it affects women about three times as much as men."
Certain headaches act like a glitch in nerve networks
“When it's a secondary headache, the cause is something like meningitis irritating nerves inside the head, or a brain tumor putting traction on painful parts of the inside of the head,” Dr. Young said. “But for the primary headache disorders—like migraine, tension headache and cluster headache—it's really a software or network disorder.
“We have this network of nerves where different parts of the brain are talking to each other, and they kind of glitch,” he added. “In the case of a migraine, they glitch for up to 72 hours, and you get all kinds of pain as well as all the other symptoms—this cascade of dysfunction within the brain that self-corrects eventually.”
Genetics partly explain who is vulnerable, but life experience fills in the rest.
“By and large, headaches are hereditary. For migraine, which is the biggest-burden headache type, it's estimated about 50% is hereditary,” Dr. Young said. “Then the rest is accumulated afflictions that you've had over your life, stresses, infections, blows to the head. All these things add up until the network is unstable and starts to give you migraine.”
Some headache symptoms require emergency care
Recognizing specific warning signs can make a major difference on outcomes and treatment choices.
“Having a very severe headache with a fever and a stiff neck, you think of meningitis,” Dr. Young said, adding that “having a progressive headache with weakness on one side, or another one-sided symptom that progresses, you think about brain tumors.”
Additionally, “you can have blood accumulating outside of the brain that can cause neurologic symptoms and some patterns of headache that are very unusual—where you can take it away completely by lying down, and it comes on very quickly when you stand up,” he said. “That can suggest a spinal fluid leak.”
“But for the most part, if you have a new and unusual headache for you that doesn't go away, or is accompanied by a neurologic symptom, you need to get medical attention and get it evaluated properly," Dr. Young said.
Primary headaches don’t have tests for diagnosing
One of the most common misconceptions about a headache is that a scan or blood test will confirm the diagnosis.
"In general, there are no tests for a primary headache. But there are tests for secondary headaches,” Dr. Young said. “When you have a primary headache, there are what we call criteria.
“You need somebody who is comfortable and experienced in seeing whether the headache meets criteria for migraine, tension-type headache or cluster headache, and is willing to make the diagnosis,” he added. “But don't expect that a test is going to prove that you have that.”
“For tension headaches, most people really don't need their doctor. The over-the-counter medicines work fine, and they may need reassurance that it's kind of normal to have episodic headaches,” Dr. Young said. “But for migraine, people need to know that they have one of the most common reasons for disabled days.
“They need to know that there's treatment,” he added. “Are the over-the-counters working? Do they need prescription medicines? Do they need to engage in lifestyle changes? Do they need to use a device to help treat their migraine attacks and control their migraine disease?”
If you experience migraine attacks, it is important “to talk to a doctor and make a plan for management—and adjust the plan,” Dr. Young said. “You'll treat a teenager who misses a couple classes a year very differently than a woman who's pregnant or going through menopause, or somebody who has daily headaches and is losing their job due to extremely frequent or continuous migraine attacks.”
Lifestyle factors matter for headaches
Sleep, stress and other daily habits genuinely influence headaches, but the conventional wisdom about dietary and environmental triggers deserves scrutiny.
“They can all affect headaches—and probably affect migraine more than other types,” said Dr. Young. “If somebody has severe insomnia, their migraine will get better if they get treatment for their insomnia.”
Meanwhile, “sleep apnea may be giving them headaches or worsening their underlying migraine disease,” he added. “Getting exercise and having good nutrition also matter.”
But Dr. Young cautions against the long lists of headache triggers that proliferate online and in popular media.
"Many of the lists of triggers that people look at are kind of mythical or if they apply to anybody, only a small minority of patients who have migraine actually have the triggers in all those lists that you see,” he said. “In large part, people who restrict everything that's delicious out of their life are really doing more harm than good."
"All headache doctors spend perhaps most of their time thinking about preventing headaches,” said Dr. Young. “Fixing a sleep disorder, managing long-term stress, getting exercise, and having good nutrition are among proven approaches.”
Additionally, “there are medications to prevent migraine, tension headache and cluster headache,” he said. “And there are devices that can prevent migraine. Some people will benefit from using a device daily or every other day in order to prevent migraine."
Migraine stigma is often a barrier to care
Of everything Dr. Young wants patients to take away, the social and psychological dimensions of migraine may carry the most urgency.
"Don't fool yourself that it's just going to stop or go away on its own,” he said. “Take it seriously, go to the doctor, talk about it, get a treatment plan, and start working on the plan—and change the plan if it's not effective for you.”
“Headache diseases have a profound impact on many people's quality of life, their work, their ability to achieve at work and socially, and not missing out on important activities in their life,” Dr. Young said. “It's not something to ignore, not something to imagine will magically go away. Think about the impact and seek treatment.”
Specialized care is available for headaches
For patients whose headaches are requiring more intensive treatment, specialized care is available.
"A specialist may not have all the skills and tools that a headache center will have, where people are really dedicating most of their work life to taking care of headache patients only,” Dr. Young said. “In those settings, you get people who have a great deal of experience, knowledge and extra study about headache diseases."
The barrier for many patients is often not awareness but shame.
"Migraine in particular is one of the most stigmatized of all chronic illnesses. People therefore don't want to let others know that they're missing work because of their migraine disease, or that this is a problem in their life,” he said. “They don't seek care. They hide the fact that they're having problems managing their migraine and they want to believe they have anything else except for migraine because they don't want to get the stigma of migraine attached to them.
“Unfortunately, that's keeping a lot of people from getting the care that they should be getting,” Dr. Young said, emphasizing that “disability is part of the disease. It's not a sign that a person is weak. It's a sign that the disease is bad."
