Headaches: Why Won’t My Head Stop Pounding?

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

Headaches suck, period. They have an infallible ability to ruin an otherwise stellar day.  Before you can treat the awful day-buster, we need to figure out exactly what type of headache you’re suffering from.  Headaches come in two varieties: primary & secondary.  Primary headaches, including migraine, tension-type and cluster, exist without outside influence. Secondary headaches, headaches with a clearly identifiable pathological cause, include withdrawal headaches as well as headaches related to high blood pressure, cervical spine issues, tumors, etc.  Luckily, most headaches present in a relatively predictable way, making them easier to identify and properly treat.  It’s about time we had some good news!

Stat Fact: The International Headache Society has classified over 300 different types of headaches.


Before we can call your headache a primary headache, we need to eliminate all possible causes of secondary headaches.  These headaches can be benign like caffeine withdrawal or a big problem like a tumor (do not freak out just yet…brain tumors are extremely rare).  Below is a list of questions that help physicians rule out scary causes of headaches.  Remember that answering yes to any of these questions is not diagnostic (meaning that we can’t confirm the headache etiology simply by answering yes). The questions simply help physicians narrow their list of possible causes and rule out more dangerous etiologies.  True diagnostic testing (MRI, CT scan) may be needed if you’re answering yes to these questions.

  • Have you experienced significant head trauma? If so, you may be at risk of a subdural or epidural hematoma.
  • Did your headache begin slowly and progress daily? Does it recur everyday?  Is it worse in the morning? Are you over the age of 50? If you answered yes to all of these questions, you have the classic characteristics of a headache caused by a tumor and should be evaluated by your physician.
  • Are you experiencing any neurological deficits like dizziness, loss of strength or sensation in part of your body, or difficulty with speech? If so, you may have suffered from a stroke or an aneurysm and should be immediately seen by a physician.
  • Are you unable to bring your head to your chest without significant pain in your neck and/or spine? If you put your chin to your chest, do you uncontrollably flex at the hips and knees?  If so, you have a classic sign of meningitis called Brudzinski’s sign and should be seen by your physician for further diagnostic testing (likely a lumbar puncture).
  • Do you have a history of cancer or HIV?  If so, you are at risk for metastatic spread of the cancer or intracranial infections (i.e. infections in your brain).
  • Have you recently started a new medication?  Have you recently stopped taking a medication? You may be suffering from a medication side effect or rebound headache.
  • Have you recently stopped smoking, drinking coffee, drinking alcohol or using recreational drugs? If so, you may be experience headaches related to withdrawal.
  • Do your headaches occur after reading or working on the computer? Have you had a recent change in your eyeglasses prescription? Your headache may be caused by eye strain.
  • Do you spend a significant portion of your day working at a desk or computer?  Is your workspace ergonomically correct?  Do you feel tension in your neck and shoulders at the end of the day?  If your workspace is not ergonomically correct, you are at risk for a tension headache caused by straining of the muscles in your neck and upper back that will transmit this tension to your scalp causing a band-like tension headache.
  • Are you exposed to toxic chemicals at home or at work?  This one is a no-brainer.
  • Have you been watching a lot of “Total Gym” commercials? You are almost certainly suffering from a Chuck Norris-induced headache.  Turn off the TV ASAP!

Stat Fact: Daily use of or withdraw from analgesics, ergotamine or NSAIDS including over the counter medications (for example, Excedrin) can cause headaches.  Rebound headaches are estimated to occur in 1% of the population.

Once the scary diagnoses are ruled out, the diagnosis of the more commonly recognized headache disorders can be pursued.

Migraine Headaches

There are a number of subtypes of migraine headaches but for the purposes of this article we will discuss the two main two forms: migraine with aura and migraine without aura.

The diagnostic criteria for a migraine without aura include the following key symptoms:

1. It lasts 4-72 hrs

2. It has at least 2 of the following:

  • Unilateral (one sided)
  • Pulsating quality
  • Aggravated by routine physical activity

3. During the headache, at least one of the following occur:

  • Nausea or vomiting
  • Photphobia (sensitivity to light) or phonophobia (sensitivity of sound)
  • Not attributed to another disorder

Migraine with aura criteria

1. Aura consists of at least one of the following without weakness:

  • Fully reversible visual symptoms (seeing flickering lights, kind of like the Kanye song)
  • Fully reversible sensory symptoms (sensation of pins and needles)
  • Fully reversible dysphasia (difficulty talking)

2. At least 2 of the following:

  • Homonymous visual symptoms (seeing half a visual field in each eye, like covering up half of the outside view on your left and half of your inside view on the right) and/or unilateral sensory symptoms
  • At least one aura symptom which lasts 5 minutes or more
  • Each symptom lasts >5 minutes and less than 50 minutes

It’s hard to keep track of all those criteria, right?  Luckily, some clever docs came up with the wonderful mnemonic, POUND, to help us remember how to diagnose a migraine headache:

  • P = Pulsatile
  • O = Over 4 hours
  • U = Unilateral
  • N = Nausea
  • D = Debilitating

How should you treat your migraine?

Migraines respond best to a treatment with medication including ergotamine (Cafegot), sumatriptan (Imitec), beta blockers (Inderal), calcium channel blockers (Verapamil).  However, there is also promising new research regarding the use of Botox for migraines.

Stat Fact: Migraines can be triggered by foods, most notably cheese, chocolate and caffeine. These headaches are rarely improved with over the counter medication. Know your triggers and do your best to avoid them!

Tension Headaches

Tension type headaches are the most common form of headache around (not a surprise, look at your poor posture reading this article!).  You’re not alone…we’re actually slouching as we write this article.  Below are some useful facts about tension headaches:

  • The most common headache presentation is in the front of the head or temple
  • They are typically not triggered by physical activity
  • The headache is almost always bilateral
  • It starts later in day, often following sitting or standing for prolonged periods of time
  • They may occur in conjunction with migraines

One way to remember the classification of migraine headaches is the abbreviation, BBT.  Instead of Bigger Better Things:

  • B = Bilaterally
  • B = Band-like
  • T = Temples or forehead

Treatment typically consist of postural education, neck and upper back strengthening, massage therapy (yes, getting yourself a nice massage is totally justified) and improving the ergonomics of your workspace.

Cluster Headaches

Cluster headaches are more rare than the aforementioned diagnoses.  Here are some details about cluster headaches:

  • Pain is most common in and around the eye, across the forehead and over the temples
  • They are 6 times more common in men than women with a mean age of 30 years old
  • They are strictly one sided
  • They are more common on right side of the face
  • They typically last on average, 30-60 minutes but can range anywhere from 15-180 minutes (much shorter than migraines)
  • Patients experiences 1-2 clusters each year
  • They are less frequently described as throbbing compared to migraine headaches
  • They are more commonly described as burning and stabbing in nature

Another clever mnemonic for you: Me as an SOB

  • M=Men
  • E=Eye
  • S=Short duration 15-180 minutes
  • O=One sided
  • B=Burning or piercing

The current treatment for cluster headaches is any of the medications from the class called triptans (also used in migraines).

Cervicogenic Headaches

We also want to take a minute to discuss one of the most commonly misdiagnosed headaches: the cervicogenic headache.  Cervicogenic headaches are not primary headaches because we know the underlying cause: neck pain.

  • They are usually unilateral but can be bilateral
  • It always occurs on the same side
  • They usually start in neck and spread to the head
  • They are triggered by neck movement or sustaining a particular posture
  • They are typically associated with a history of trauma
  • They are more common in females
  • In contrast to a tension-type headache, neck movement will always increase headache symptoms
  • They are aggravated by specific neck postures or movements

These forms of headaches can be treated with massage therapy, improving the ergonomics of your workspace, and neck strengthening (sound familiar?).

Take Home Messages

  • Proper diagnosis is the most important step in headache management.  Know the type of headache, because BBT can happen to a Me SOB without the POUNDing.  Once you have the correct diagnosis, treatment is simple and straightforward.
  • Headaches can be managed by a comprehensive team of medical professionals including primary care physicians, neurologists, and physical therapists.
  • Be careful of medication-induced headaches.  Your attempt at treatment might actually be the underlying problem!

References:

1. Clinch CR. Evaluation of acute headaches in adults. Am Fam Physician. Feb 2001;63(4):685-692.

2. Haldeman S, Dagenais S. Cervicogenic headaches: a critical review. Spine J.2001 Jan-Feb 2001;1(1):31-46.

3. Lewis JB, Frohman EM. Diagnosis and management of headache. Obstet Gynecol Clin North Am. Jun 2001;28(2):205-224, v.

4. Smetana GW. The diagnostic value of historical features in primary headache syndromes: a comprehensive review. Arch Intern Med. Oct 2000;160(18):2729-2737.

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03 2011

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