Types of Headache

Tension headache. It is the most common. It is caused by muscular tension, generally of the forehead and nape of the neck, and usually coincides with periods of stress. This type of headache presents as a persistent tension or pressure, like a helmet, in both sides of the head and predominantly in the forehead and nape of the neck. In many cases, palpation of the muscles affected can induce pain. The intensity of the pain in tension headaches is usually milder and less disabling when compared to cephalalgia caused by migraine or to secondary headaches. The pain usually starts during the day, and is more intense in the afternoon, but it may become chronic, and be present all day for several days.

Migraine or severe Cephalalgia. It is characterised by repeated or recurrent episodes of headache. The intensity can vary in the different episodes, but can be intense, which is when the patient requests medical care. The pain generally begins on one or other side of the head (hemicranial) and spreads to the whole head. It is usually pulsatile, like the beat of the heart, and may be accompanied by nausea and vomiting, as well as a discomfort that gets worse with light (photophobia), noise (phonophobia), and smells (osmophobia). The pain gets worse with physical activity, improves with rest, and can be triggered by periods of stress, changes in sleep pattern (sleep less, or even more than usual), menstruation, climate changes, fasting, or hunger, or some foods.

Migraine can be hereditary, and it is common to find a family history of migraine. It can present as aura migraine (20%) —in which the headache is preceded by visual, sensory, speech or motor symptoms— or as migraine without aura (80%). A patient with an aura migraine can have headache episodes with no aura.

A chronic form is also distinguished, that is to say, patients that suffer from headache more than 15 days a month (could be a migraine or tension), of which at least 8 of them fulfil migraine criteria. Around 2.5% of patients a year go from the episodic to the chronic form. There are some predisposing factors to developing this chronic form of cephalalgia and they are grouped into:

• Non-modifiable factors, like being a woman, a low economic status, or a history of head traumas.
• Modifiable factors, such as an increased frequency of stress, obesity, abuse of analgesic medication, stress, anxiety, depression, caffeine abuse, the presence of other painful symptoms, such as fibromyalgia.

Trigeminal autonomic cephalalgia. Different situations with common clinical characteristics are grouped together: one-sided pain located in the area innervated by the trigeminal nerve and autonomous cranial symptoms (watery eyes, red eye, congestion, or nasal packing, flow of liquid from the nose or rhinorrhoea, facial sweating). They are short-duration and very intense headaches, and with several episodes a day.

The pain and the autonomous symptoms are due to the activation of the trigeminal nerve and the parasympathetic nerve system as a result of the pathological activation of the facial-trigeminal reflex in the brainstem. The hypothalamus is the brain region that acts as a generator that activates this reflex.

Three situations are distinguished, in which the duration and frequency of the attacks help to identify them and thus be able to give specific treatment:

• Cluster headache. It is the most common group. It affects less than 1 in 1,000 adults, being three times more common in males than in females, and usually begins around 30 years of age.It presents as very intense daily or almost daily episodes (between 1 and 8 times, and each episode lasting from 15 to 180 minutes), and also appear at night. The patient is restless, unlike with migraine that prefers to be stretched out and still. The duration of the pain outbreak periods varies between a few weeks and several months, with headache-free intervals, being repeated annually or every few years and, occasionally, it becomes chronic with consecutive outbreaks for more than 1 year. The triggers to avoid are stress, tobacco, alcohol, and naps during periods of pain attacks.
• Hemicranial headache. It affects 1 in 50,000 adults and is three times more common in females than in males, usually in adults. It presents in a form of very tense and short episodes with a duration of between 2 and 30 minutes (generally less than 15 minutes) more than 5 times a day. The location is always on one side and responds to the anti-inflammatory drug, indomethacin.There are two variants: paroxysmal (20% of patients) with long periods free of attacks, and chronic (80%).
• Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT). It is a very rare situation and its prevalence is unknown. It is slightly more common in males and usually appears around 50 years-old. It presents in a form of very short episodes of moderate-severe intensity, between 5 seconds and, rarely, minutes, repeatedly until up to 200 times a day. They can appear spontaneously, or be triggered by touching the face or the scalp, brushing the teeth, sneezing, shaving, etc.

Cough headaches. It is caused by coughing or due to a Valsalva manoeuvre (increase in intra-thoracic, or secondarily intracranial, pressure when sneezing, defecating, lifting weight, etc.). It lasts between 1 second and 30 minutes, a subsequent discomfort persisting for a few hours. Although the majority are primary headaches, it is important to perform an imaging test such as a cranial computed tomography (CT) or brain resonance scan in order to rule out intracranial lesions that increase the pressure.

Headache due to physical effort. It is caused by performing very intense physical exercise. They are usually pulsatile types, and last between 5 minutes and 48 hours. Occurs more frequently in places where it is very hot or at high altitudes. Improves on stopping the activity. Although the majority are primary headaches, it is important to perform an imaging test to rule out secondary causes; the most frequent being brain haemorrhage or subarachnoid haemorrhage.

Headache associated with sexual activity. It is triggered by sexual activity. It may be pre-orgasmic or orgasmic, with the latter being more common. The pain occurs in the sides of the head, reaching its peak when the orgasm comes and last from minutes to hours. Like that in headache due to physical effort, an imaging test should be performed to rule out intracranial or cerebrovascular lesions.

Cold stimulus headache. It is triggered by something very cold, it may be due to touching the exterior part of the head, or due to inhaling or ingesting, as happens with ice creams. The pain of cold stimulus headache tends to be stabbing, one-sided and of short-duration.

Hypnic headache. It only appears while sleeping, making the patient wake up. It usually affects people over 50 years-old, and tends to be persistent, between 30-180 minutes. It is unspecific, although it shares some characteristics with migraine, such as a feeling of nausea. It is important to rule out a secondary cause when it is of recent onset.

Trigeminal neuralgia. It is defined as episodes of facial pain on one side of the face, and affects one or more of the three branches of the trigeminal nerve without radiating to other areas. It is characterised by an acute, stabbing or electric pain, with an unexpected beginning and end. It last seconds, and is usually triggered by external stimuli in the “trigger areas” when, for example, shaving, washing the face, blowing the nose, speaking, chewing.

The cause is unknown in the majority of cases, and it mostly affects women over 40 years of age. From 5 to 10% are caused by diseases such as tumours, base of the skull anomalies, cerebral infarction, arterio-venous malformations, multiple sclerosis, etc. A brain magnetic resonance with 3-dimensional reconstruction has to be performed for its diagnosis.