The Causes Of Headaches And Headache Symptoms

There are many causes of headache according to the headache type you may have. Headache comes in many different guises, not just migraine. Below lists some of the major different types of headache. Stress is often causative and aggravates the pain experience (see What is the SPI). In other headache types, the initial causative factor may involve a sensitivity to specific foodstuffs, eyestrain, viral or bacterial infection, head/neck injury, carbon monoxide poisoning, tiredness and very rarely tumour as the initial causative factor. A proper diagnosis can only be made by your personal doctor or health professional. In any medical condition it is of paramount importance for the diagnosis to be accurate and can only be made by your health professional or physician (MD) who knows your private medical history in detail. Only after this has been achieved it is unlikely that a good headache management plan will be established. It is possible to have more than one type of head pain.

Causes Of Migraine Headaches:

Migraine is often triggered by several factors.
Environmental factors: Build up of tiredness over the working week, emotion and stress (eg, anger) (see What is the SPI), missed meals (hypoglycaemia), smoke, strong odours (eg, perfume, paint), too much/little sleep, weather changes, bright/flashing lights,
Hormonal changes: Hormone replacement therapy (HRT), menstruation, oral contraceptives, pregnancy.
Exercise or exertion: Eye strain, head injury, irregular/no exercise.
Food/Ingredients: Alcohol, artificial sweeteners, caffeine, chocolate, cultured dairy products fermented/pickled foods, fruits, mature cheese, monosodium glutamate, nitrates (eg, in cured meats), sugar, sulphites, vegetables, yeast.

Migraine drug treatments often now include the triptans. Triptans appear to work by stimulation of 5-HT1B and 5-HT1D receptors. During a migraine attack, the trigemino-vascular system is activated, particularly peripheral blood vessels and the trigeminal nerve. This nerve communicates peripherally with these blood vessels and centrally with the trigeminal nuclei. The important receptors are serotonergic, as the blood vessel is driven by the 5-HT1B and the trigeminal nerve by the 5-HT1D subtypes at both ends. In the UK, there are four licensed triptans - sumatriptan (Imigran® or Imitrex®), zolmitriptan (Zomig®), naratriptan (Naramig ® or Amerge®) and rizatriptan (Maxalt®). All these drugs are used in clinical practice but the mainstay is still sumatriptan. Three newer drugs from this family are eletriptan, frovatriptan and almotriptan.

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Causes Of Tension Headaches:

Muscle Contraction Headache or Acute Tension Type Headache occurs in about 50% of the population on a monthly basis but is usually low impact which is why it is not seen a lot in primary care. The exact causes of tension headache are not known but stress and tension play a part. Typically the tension headache is mild to moderate only, non-pulsating and bilateral. Sensory sensitivity to noise or light is more likely to be associated with migraine. Difficulties arise when patients who are suffering from migraine are misdiagnosed as having tension headaches. They then do not receive appropriate pain management. Patients often describe their head pain as a "feeling of tightness or squeezing'. It is possible but rare to get tension headache without exacerbations -causing daily or near daily background symptoms.

Causes Of Chronic Headaches:

Chronic Daily Headache risk factors appear to include not only a past history of migraine and high analgesic intake, but also injuries to the head and neck, such as a whiplash injury. The aim of management in Chronic Headache is to return patients to their original acute headache pattern. Stress can aggravate the condition.

Causes Of Cluster Headaches:

Cluster headache is an excruciating condition that is fortunately rare. The exact cause is not known. It affects 1 in 1000 men and 1 in 6000 women; most are in their twenties or older and many are smokers. It is characterised by frequently recurrent, short lasting headache and autonomic symptoms. Cluster headache is highly recognisable. The episodic form occurs in bouts (clusters), typically of 6-12 weeks' duration once a year or every two years and at the same time of year. Strictly unilateral intense pain around the eye develops once or more daily, commonly at night. The cluster headache is sudden in onset and lasts between 15 -180 minutes and can occur between once a day to eight times a day. The eye is red and waters, the nose runs or is blocked on that side, and ptosis (droopy eyelid) may occur. Atypical presentations are more common in women. In the chronic form, which is less common, no remissions occur between clusters, and a continuous milder background headache may additionally develop. The episodic form can become chronic, and the chronic form episodic, but once present, cluster headaches can persist for 30 years or more.

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Causes Of Icepick Headaches:

Icepick Headache is typically seen in the young to middle aged and patients describe a short piercing pain like a flash of lightening lasting from seconds to minutes and may occur several times a day. Icepick headache usually involves one eye and bruised after the pain has gone. Some patients find cold foods trigger the pain. Sometimes the patient has multiple attacks per day on a daily basis. The exact causes of this type of head pain are unknown.

The Causes Of Sinusitis (Sinus Headache):

Sinusitis is caused by infection of one or more of the cranial (skull) sinuses. These are the bony inner structures of the skull. Acute sinusitis lasts for days to up to three weeks. The International Headache Society's criterion of purulent discharge and acute febrile illness is indicative of acute sinusitis. The site of the pain varies according to the location of the infection. Maxillary sinusitis pain is mostly in the cheek, gums, teeth and upper jaw. When pain is presented between and around the eyes this is referred to as ethmoidal sinusitis. Frontal sinusitis pain is seen in the forehead and sphenoidal sinusitis presents with pain at the crown of the head. The head pain often has a a dull aching quality which is worsened by bending. Very rarely complications can occur such as meningitis or abscesses.

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Trigeminal Neuralgia Causes:

Trigeminal Neuralgia most common cause thought to be vascular compression resulting from abnormal arterial roots near the nerve root. MRI scans can confirm this. Other possible causes include malignancy, multiple sclerosis, intra- cranial aneurysms and cranial arteritisis considered to be the most common neurological syndrome in the elderly. Women are three times more likely to get it than men. Over 95% of cases are unilateral. The pain is often described as an electric shock or spasm or burning sensation in one or more of the three divisions of the trigeminal nerve. The pain lasts from 2-120 seconds. The ophthalmic division supplies the forehead, eyes and scalp, the maxillary supplies the cheek and the mandibular supplies the lower cheek, lower lip and chin. The condition has been called 'tic douloureux' because the facial muscles may twitch. Patients can sometimes have a dull ache as a continuous symptom. The trigger can be cold air, washing the face or cleaning the teeth. The pain can be excruciating.

Post Herpetic Neuralgia Causes:

Post-Herpetic Neuralgia from Shingles (herpes zoster virus) can cause pain resulting from various cranial nerves. The pain may start during an acute rash of herpes but the main problem is pain that persists after the herpes rash has gone. Common Post Herpetic Neuralgia symptoms include a constant deep pain, with repeated stabs, or needle pricking pain. Even light touch can trigger these symptoms which may be accompanied by itching. Half of patients have no pain after three years.

TJM Causes:

Temporomandibular Joint Dysfunction requires the expertise of a dentist. Each side of the jaw is hinged to the skull and this joint is known as the temporomandibular joint (TMJ). Low grade muscle contraction type headache or migraine can result from temporomandibular joint dysfunction. Possible causes include new dental fillings which may unbalance the bite, grinding the teeth while asleep (Bruxism) and continued stress during the day (See Short Pain Inventory) can initiate and exacerbate the pain.

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Causes Of Sinister Headache (Meningitis):

Sinister Headache needs expert medical and or neurological examination. The main question is how can we recognise a sinister headache. The major red flag is age. Three-quarters of migraine sufferers have their first migraine by the age of 30 and it is increasingly less likely that the first attack be much above 30. Abrupt onset with vomiting is another warning. The patient should seek expert medical opinion. Causes of sinister headache that must not be missed include:

1. Meningitis: usually accompanied by fever and neck stiffness in an obviously ill patient.
2. Intracranial tumours: produce headache when they are large enough to cause raised intracranial pressure, which is usually apparent from the history. Papilloedema or focal neurological signs, or both, will usually be present. Fortunately these are very rare.
3. Subarachnoid haemorrhage: headache is often described as the worst ever, and is usually (but not always) of sudden or ictal onset. Neck stiffness may take hours to develop. In elderly patients particularly, classic symptoms and signs may be absent.
4. Temporal arteritis: headache is persistent but often worse at night and sometimes severe, in a patient over 50 who does not feel entirely well. It may be accompanied by marked scalp tenderness.
5. Primary angle closure glaucoma: rare before middle age, may present dramatically with acute ocular hypertension, a painful red eye with the pupil midodilated and fixed and, essentially, impaired vision, and nausea and vomiting. In other cases, headache or eye pain is episodic and mild. The diagnosis is suggested if patient reports coloured halos around lights.
6. Idiopathic intracranial hypertension: rare cause of headache; occurs especially with obese young women. May not be evident on history alone; papilloedema indicates the diagnosis.
7. Subacute carbon monoxide poisoning: uncommon but potentially fatal. Symptoms include headaches, nausea, vomiting, giddiness, muscular weakness, dimness of vision, and double vision.

Source: Dr Andrew Dowson

Publication Date: July 2003

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