What kinds of headaches are there and what are their symptoms?

Conventionally, headaches are divided into common migraine, classical migraine, cluster headaches and tension headaches. However, anyone who suffers regularly from headaches will know that the distinctions are sometimes very blurred, with the severe migraine type headache blending into what is for many people, a normal daily headache.

Common migraine is generally described as a throbbing pain, often on one side of the head behind the eye, accompanied by nausea with or without vomiting, which becomes more generalised as the day wears on. Bright lights and noise may aggravate it, and rest in a dark room will ease it. These are supposed to occur at intervals of weeks or months, although many people describe them as much more frequent.

Classic migraine is very similar, but is often heralded by visual disturbances such as flashing lights, dazzling zigzag lines, intolerance of bright lights, blockage of parts of the visual field, dizziness, tingling in the hands and a ringing in the ears (tinittus). The headache then starts, generally on one side of the face, is throbbing in nature and accompanied by nausea and vomiting.

In so-called complicated migraine the neurological disturbances can be even more profound, sometimes mimicking a mild stroke.

Cluster headaches are a fairly distinct entity, tending to occur in men who will often wake at night with an intense, non-throbbing pain behind one eye. The affected eye also waters profusely and the nose may become blocked. These headaches tend to occur in "clusters", hence the name. A person may experience many over a period of a few days, and then not have another headache for months or years.

Tension headache is often bilateral, usually extending from the neck to over the top of the head, where the pain will sit like a tight band. These may occur daily, and when experienced less frequently, will often last for more than one day. Sufferers may also describe features usually associated with migraine such as nausea and an intolerance of bright lights.

As I've said above, these distinctions are seldom absolute, many people suffering from what is known as "combination" headaches, where they experience both migrainous symptoms and daily tension headaches. Cluster headaches, however, tend to be a discrete entity.

When should you be concerned that a headache is serious?

Of course, all headaches are serious to those who experience them, particularly if you are one of those unlucky people who suffer them regularly. But, there are signs that a headache is an indication of an underlying condition which needs more than pain relief.

In children meningitis is always the first thing that a worried parent will think of, particularly if the child also has a fever. Fever by itself can cause a severe headache. Signs to watch for are a very high fever, complaints of being unable to move the head because the neck is stiff, vomiting and, in some infections, a fine reddish-purple rash in patches on the body.

A headache caused by an increase in pressure within the brain cavity from an aneurysm or consequent bleed will vary in its intensity, often getting worse on bending forward or coughing or sneezing. The onset may be acute, with pain reaching a peak within minutes. It generally happens over a very short period of time, and there may have been no history of headaches before. There may also be other signs in the rest of the body, such as problems with vision and hearing, weakness in the limbs and loss of sensation.

Although headache is one of the main symptoms of a brain tumour, the quality of the pain is not specific. It may be deep seated and throbbing, attacks lasting from a few minutes to an hour or more. As the tumour grows, the attacks become more frequent, consciousness may decline and there may be vomiting.

A number of medical conditions will cause headaches, although headaches are not generally one of their diagnostic symptoms. As mentioned above, fevers will cause headache, as will lack of oxygen as in chronic lung disease. Problems with the adrenal and thyroid glands can cause headaches. Headache may be a feature of HIV infection, even when there is no underlying meningitis.

Epilepsy may mimic migraine, so, particularly in migraine occurring after head injury, or for the first time quite late in life, investigations to rule it out would be advisable.

What causes headaches?

Apart from the headaches associated with definite pathology, as described above, the cause of headaches is controversial. Muscle tension in the head and neck certainly plays a large part, and, if you believe that migraine is just part of a spectrum with tension headaches, then muscle tension could be a contributing factor in migraines as well. There do seem to be changes in the brain's blood flow in migraine, but equally, patients with migraine can be demonstrated to have high levels of muscle tension in their head and neck. Since dizziness is not an uncommon symptom in tension headache patients, then perhaps there are also some disturbances in blood flow associated with tension headache as well.

Many people have so-called "trigger factors" which provoke a headache, such as red wine, cheese and chocolate. But equal numbers of people can find nothing which they associate with their headaches.

Treatment

Treating headaches, particularly chronic ones, can be a minefield.

Irregular migraines are generally well managed with a combination of rest and often very simple painkillers such as Disprin®. More regular migraines are generally managed with more powerful drugs such as sumatriptan (Imigran®). Ergot preparations, such as Cafergot® are also used. But both of these have serious side effects and are not well tolerated by some people. Studies in Europe have found that a simple, inexpensive combination of Maxalon® (metaclopramide, an anti-nausea preparation) and Disprin® is as effective, and has fewer side effects than Imigran®. Regular use of medications such as Sandomigran® and Sibelium® may prevent migraines, but the efficacy tends to wear off, and the drugs have many side effects. A low dose of a beta-blocker, Inderal® will often help to prevent migraine.

Cluster headaches are generally managed in the same way as migraine.

Unfortunately, all the ergot preparations, and most other painkillers, particularly those containing caffeine and codeine, will actually cause headaches if used over long periods of time. So, anyone who has regular headaches, and a high weekly intake of painkillers, will, in time, find that their headaches are becoming more and more frequent. So, a vicious cycle is set up, in which headaches become more frequent, so more pain killers are used, eventually resulting in the chronic daily headaches which are so common. The combination painkillers such as Syndol® and Suncodin® which contain codeine and caffeine are particularly bad. Severe migraine sufferers have landed up as Pethidine® addicts through no fault of their own, when that has been the only painkiller which will relieve the migraine.

So, what can you do? Many migraines can be controlled well with Maxalon and Disprin, as mentioned before. Daily headaches will often respond to relaxation techniques and massage. If you are aware that you are in a cycle of daily headaches and painkiller use, then see your GP to discuss ways of breaking that cycle. Low doses of antidepressants combined with anti-inflammatory medications will often allow a person to get over the withdrawl stage.

If you suffer from chronic headaches of any type, don't allow people to frustrate you by their tendency to trivialise a headache. Chronic headaches are a debilitating, life disturbing phenomenon, which few people who do not suffer them can understand. There are ways of controlling headaches. Keep on until you find what is right for you.