Different Types of Headache. Migraine, Tension, Cluster, Chronic, TMJ, Trigminal Neuralgia and Sinister Headache Types

Headache comes in many different guises, not just migraine. Below lists some of the major headache types. A proper diagnosis can only be made by your doctor or health professional.


Migraine is a severe headache type and can have a considerable impact on the daily life of sufferers and affects between 17 per cent of women and 6 per cent of men, although estimates vary. Accurate diagnosis of the different presentations of migraine is the foundation of effective prescribing and management.

Diagnostic pointers for migraine.

1. Attacks last from 4 to 72 hours
2. Patients are usually symptom-free between attacks
3. Headache is at least two of the following
a. Unilateral (on one side)
b. Pulsating
c. Moderate to severe
d. Aggravated by routine activities
4. Accompanying symptoms may include
a. Photophobia (more sensitive to light)
b. Phonophobia (more sensitive to noise)
c. Nausea and Vomiting

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 management plan will be established. In the late 1980s, the International Headache Society (IHS) formulated a classification for migraine, which has helped us to determine the correct patient groupings for migraine clinical trials. If five headache attacks meet the criteria, the patient is given the diagnostic label of "migraineur". It is important to realise that not all four main symptoms have to be present. It is quite possible for the patient to have a mild headache which is bilateral, but still have migraine.

Recently clinicians have realised that it is helpful to ask questions of patients with acute or intermittent headaches. Information about their quality of life and ability, or otherwise, to perform normal activities is very important. High impact, acute headache would, therefore, tend to have a default diagnosis of migraine and the IHS classification is used to confirm this.

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The main part of the classification is concerned with the headache phase of the attack. However, approximately 10 per cent of patients will have reversible sensory symptoms in the hour preceding the headache. These symptoms are known as aura and will often include visual changes, such as zigzag lines or scotoma (holes in the vision), but a variety of other symptoms may also occur. Other symptoms include, dizziness, numbness and "word salading" (words being mixed up). About 40 per cent of patients describe more vague symptoms of aura that can last substantially longer. In the day or two before an attack, prodromal symptoms, such as cravings and lethargy, can be observed. From within these two groups of symptoms, useful warnings can be identified and patients taking simple treatments during such a warning may have success in heading off a migraine before it has started. Often ignored is the postdrome phase of migraine. Once the headache has subsided the postdrome usually involves the patient feeling quite washed out or hung-over. A few patients may feel entirely the opposite, almost as if they are super-human. Relatively little can be done to alleviate these prodromal symptoms, the cost in terms of disruption to work, relationships, and social activities, which can result from this phase of the attack can be considerable.

Trigger Factors For Migraine:

Environmental factors: Build up of tiredness over the working week, emotion and stress (eg, anger), 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.

Muscle Contraction Headache Type/Acute Tension Headache Type

Muscle Contraction Headache or Acute Tension Headache Type 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. Typically this headache type 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 a tension headache type. They then do not receive appropriate management. Patients often describe the pain as a "feeling of tightness or squeezing'. The causes of tension headache type are not known. It is possible but rare to get a tension headache type without exacerbations - causing daily or near daily background symptoms. This is part of the Chronic Daily Headache Syndrome and needs managing as such.

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Chronic Daily Headache Type

Chronic Daily Headache is defined as a headache type which is present on most days ie > 15 days a month, typically occurring over a six-month period or longer and it can be daily and unremitting. In some patients, an episode of chronic headache resolves in a much shorter time. It can occur in children and in the very old. Twice as many men have it compared to women. The symptoms can last for decades and typically patients may have suffered for up to five years before presenting to a specialist centre.

About 50% of patients attending a doctor with a headache will have Chronic Daily Headache. Many different classifications have been used to describe Chronic Daily Headache including medication misuse headache, hemicrania continua and transformed migraine. Chronic Daily Headache Type is characterised by a combination of background, low-grade muscle contraction-type symptoms, often with stiffness in the neck, and superimposed migrainous symptoms. Patients might have had migraine in the past and experienced a difficult patch of high frequency headache, prompting them to increase their analgesic intake. These analgesics can then lead to a worsening of the chronic headache pattern resulting in analgesic dependence.

In the United Kingdom, the most commonly implicated drugs are those containing codeine but all simple analgesics and ergotamine compounds have been implicated. In recent times, the triptan class of drugs has also been reported to cause chronic headache, although it is our opinion that this situation is uncommon. However, the medication probably does not actually cause the condition. It is more likely that patients achieve transient relief from this class of drug, leading them to repeat dosing. 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 Daily Headache Type is to return patients to their original acute headache pattern, which requires a combination of treatments including:

  • Identify Stressors in your life and reduce sources of stress ( SPI © test).
  • Physical measures in the neck and shoulder areas (eg, exercises or formal physiotherapy, acupuncture or osteopathy or chiropractic).
  • Avoidance of analgesics and ergotamine to break the cycle.
  • Use of effective, regular prescription medicines, usually drawn from the antidepressant or antiepileptic groups.

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    Cluster Headache Type

    Cluster headache is an excruciating condition that is fortunately rare. 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 Type 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. This headache type 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 headache can persist for 30 years or more.

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    Ice Pick/Ice cream Headache Type

    Typically the patient is 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. Ice-Pick headache Type 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.

    Sinister Headache Type

    Meningitis/Subarachnoid Haemorrhage/Cranial Arteritis. The main question is how can we recognise a sinister headache type! The major red flag is age. Three-quarters of migraine sufferers have had 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.

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    Causes of headache that must not be missed

    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.

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    Facial Headache Types

    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 up to three weeks. The International Headache Society's criterion of purulent discharge and acute febrile illness is indicative of acute sinusitis (sinus headache). 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 pain often has a a dull aching quality which is worsened by bending. Very rarely complications can occur such as meningitis or abscesses.

    Post Herpetic Neuralgia 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 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.

    Trigeminal Neuralgia

    Trigeminal neuralgia is 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. The most common cause is 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, intrac cranial aneurysms and cranial arteritis.

    Temporomandibular Joint (TMJ)

    Each side of the jaw is hinged to the skull and this joint is known as the temporomandibular joint (TMJ). Low grade muscle contraction headache type 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.

    Source: Dr Andrew Dowson

    Publication Date: July 2003


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