Prepared by:

Office of Communications and Public Liaison

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Department of Health and Human Services

Bethesda, MD 20892-2540

NIH Publication No. 09-158 

August 2009

Why does bright light or noise hurt 

when you have a headache? Why is sleep 

important? How does stress cause headache? 

Basic research tries to answer questions like 

these as we learn how messages are sent and 

influence different parts of the brain. Findings

from such studies can lead to improved 

patient care and headache prevention.

 

 

 
This pamphlet was written and published by 

the National Institute of Neurological Disorders 

and Stroke (NINDS), the United States’ leading 

supporter of research on disorders of the brain 

and nervous system, including headache. NINDS, 

one of the U.S. Government’s National Institutes 

of Health in Bethesda, Maryland, is part of the 

Public Health Service within the U.S. Department 

of Health and Human Services. 
Table of Contents
 

Introduction ............................................. 1
 

Why Headaches Hurt.................................. 3
 

When to See a Doctor.................................. 4
 

Diagnosing Your Headache........................... 5
 

Headache Types and Their Treatment ............. 6
 

Primary Headache Disorders, 

including Migraine ................................ 6
 

Secondary Headache Disorders ...............25
 

Children and Headache ..............................34
 

Headache and Sleep Disorders .....................35
 

Coping with Headache................................36
 

What Research is Being Done? .....................37
 

Where Can I Find More Information? ............44
 

Glossary .................................................46
 

This brochure has been designed to help you better 

understand headaches and how they are treated. 

Knowing about headaches will make it easier for 

you to discuss your symptoms and concerns with 

your doctor. 
ii
 
Introduction
 

Headaches are the most common form of pain 

and range in frequency and severity. Without 

proper treatment headaches can interfere with 

daily activities. 

You’re sitting at your desk, working on a difficult 

task, when it suddenly feels as if a belt or vice is 

being tightened around the top of your head. 

Or you have periodic headaches that occur with 

nausea and increased sensitivity to light or sound. 

Maybe you are involved in a routine, non-stressful 

task when you’re struck by head or neck pain. 

Sound familiar? 

If so, you’ve suffered 

one of the many 

types of headache 

that can occur on 

its own or as part of 

another disease or 

health condition. 

Anyone can experience a headache. 

Nearly 2 out of 3 

children will have 

a headache by age 15. More than 9 in 10 adults 

will experience a headache sometime in their life. 

Headache is our most common form of pain and 

a major reason cited for days missed at work or 

school as well as visits to the doctor. Without 

proper treatment, headaches can be severe and 

interfere with daily activities. 

Certain types of headache run in families. Episodes 

of headache may ease or even disappear for a time 

and recur later in life. It’s possible to have more 

than one type of headache at the same time. 

1 
2 

Primary headaches1 occur independently and 

are not caused by another medical condition. 

It’s uncertain what sets the process of a primary 

headache in motion. A cascade of events that 

affect blood vessels and nerves inside and outside 

the head causes pain signals to be sent to the 

brain. Brain chemicals called neurotransmitters 

are involved in creating head pain, as are 

changes in nerve cell activity (called cortical 

spreading depression). Migraine, cluster, and 

tension-type headache are the more familiar 

types of primary headache. 

Secondary headaches are symptoms of another 

health disorder that causes pain-sensitive nerve 

endings to be pressed on or pulled or pushed 

out of place. They may result from underlying 

conditions including fever, infection, medication 

overuse, stress or emotional conflict, high blood 

pressure, psychiatric disorders, head injury or 

trauma, stroke, tumors, and nerve disorders 

(particularly trigeminal neuralgia, a chronic 

pain condition that typically affects a major 

nerve on one side of the jaw or cheek). 

Headaches can range in frequency and severity 

of pain. Some individuals may experience headaches once or twice a year, while others may 

experience headaches more than 15 days a month. 

Some headaches may recur or last for weeks at 

a time. Pain can range from mild to disabling 

and may be accompanied by symptoms such as 

nausea or increased sensitivity to noise or light, 

depending on the type of headache. 

1 Words in italics appear in the Glossary found at the end of this document. 
Why Headaches Hurt
 

Information about touch, pain, temperature, 

and vibration in the head and neck is sent 

to the brain by the trigeminal nerve, one of 

12 pairs of cranial nerves that start at the base 

of the brain. The nerve has three branches 

that conduct sensations from the scalp, the 

blood vessels inside and 

outside of the skull, the Headaches can signal 

lining around the brain a more serious disorder 

(the meninges), and the that requires prompt 

face, mouth, neck, ears, medical care. 

eyes, and throat. 

Brain tissue itself lacks pain-sensitive nerves 

and does not feel pain. Headaches occur when 

pain-sensitive nerve endings called nociceptors 

react to headache triggers (such as stress, 

certain foods or odors, or use of medicines) 

and send messages through the trigeminal 

nerve to the thalamus, the brain’s “relay 

station” for pain sensation from all over 

the body. The thalamus controls the body’s 

sensitivity to light and noise and sends 

messages to parts of the brain that manage 

awareness of pain and emotional response 

to it. Other parts of the brain may also be 

part of the process, causing nausea, vomiting, 

diarrhea, trouble concentrating, and other 

neurological symptoms. 

3 
 

	 	 	 	 	 	

	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

4 

When to See a Doctor
 

Not all headaches require a physician’s attention. 

But headaches can signal a more serious disorder 

that requires prompt medical care. Immediately 

call or see a physician if you or someone you’re 

with experience any of these symptoms: 

•	 Sudden, severe headache that may be

accompanied by a stiff neck. 

•	 Severe headache accompanied by

fever, nausea, or vomiting that is 

not related to another illness. 

•	 “First” or “worst” headache,

often accompanied by 

confusion, weakness, 

double vision, or loss 

of consciousness. 

•	 Headache that worsens over days or weeks

or has changed in pattern or behavior. 

•	 Recurring headache in children.

•	 Headache following a head injury.

•	 Headache and a loss of sensation or weakness

in any part of the body, which could be a sign 

of a stroke. 

•	 Headache associated with convulsions.

•	 Headache associated with shortness of breath.

•	 Two or more headaches a week.

•	 Persistent headache in someone who has

been previously headache-free, particularly 

in someone over age 50. 

•	 New headaches in someone with a history of

cancer or HIV/AIDS. 

A sudden, severe headache 

accompanied by a stiff neck, 

or by fever, nausea, or vomiting 

requires prompt medical care. 
 

 

Diagnosing Your Headache 

How and under what circumstances a person 

experiences a headache can be key to diagnosing 

its cause. Keeping a headache journal can help a 

physician better diagnose your type of headache 

and determine the best treatment. After each 

headache, note the time of day when it occurred; 

its intensity and duration; any sensitivity to light, 

odors, or sound; activity immediately prior to the 

headache; use of prescription and nonprescription 

medicines; amount of sleep the previous night; any 

stressful or emotional conditions; any influence 

from weather or daily activity; foods and fluids 

consumed in the past 24 hours; and any known 

health conditions at that time. Women should 

record the days of their menstrual cycles. Include 

notes about other family members who have a 

history of headache or other disorder. A pattern 

may emerge that can be helpful to reducing or 

preventing headaches. 

Once your doctor has reviewed your medical and 

headache history and conducted a physical and 

neurological exam, lab screening and diagnostic 

tests may be ordered to either rule out or identify 

conditions that might be the cause of your headaches. 

Blood tests and urinalysis can help diagnose brain 

or spinal cord infections, blood vessel damage, 

and toxins that affect the nervous system. Testing 

a sample of the fluid that surrounds the brain and 

spinal cord can detect infections, bleeding in the 

brain (called a brain hemorrhage), and measure any 

buildup of pressure within the skull. Diagnostic 

imaging, such as with computed tomography (CT) 

and magnetic resonance imaging (MRI), can 

detect irregularities in blood vessels and bones, 

5 
 

 

 

6 

certain brain tumors and cysts, brain damage 

from head injury, brain hemorrhage, inflammation, 

infection, and other disorders. Neuroimaging also 

gives doctors a way to see what’s happening in the 

brain during headache attacks. An electroencephalogram (EEG) measures brain wave activity and can 

help diagnose brain tumors, seizures, head injury, 

and inflammation that may lead to headaches. 

Headache Types and Their Treatment 

The International Classification of Headache 

Disorders, published by the International Headache 

Society, is used to classify more than 150 types of 

primary and secondary headache disorders. 

Primary headache disorders are divided into 

four main groups: migraine, tension-type 

headache, trigeminal autonomic cephalgias (a 

group of short-lasting but severe headaches), 

and a miscellaneous group. 

Migraine 

If you suffer from migraine headaches, you’re not 

alone. About 12 percent of the U.S. population 

experience migraines, one form of vascular headaches. Vascular headaches are characterized 

by throbbing and pulsating pain caused by the 

activation of nerve fibers that reside within the 

wall of brain blood vessels traveling within the 

meninges. Blood vessels narrow, temporarily, 

which decreases the flow of blood and oxygen 

to the brain. This causes other blood vessels to 

open wider and increase blood flow. 
 

 

 

 

 

 

 

 

 

Migraines involve recurrent attacks of moderate 

to severe pain that is throbbing or pulsing and 

often strikes one side of the head. Untreated 

attacks last from 4 to 

72 hours. Other common 

symptoms are increased 

sensitivity to light, noise, 

and odors; and nausea and 

vomiting. Routine physical 

activity, movement, or even 

coughing or sneezing can 

worsen the headache pain. 

Migraines occur most frequently in the morning, 

especially upon waking. Some people have migraines 

at predictable times, such as before menstruation or 

on weekends following a stressful week of work. Many 

people feel exhausted or weak following a migraine 

but are usually symptom-free between attacks. 

A number of different factors can increase your risk 

of having a migraine. These factors, which trigger the 

headache process, vary from person to person and 

include sudden changes in weather or enviroment, 

too much or not enough sleep, strong odors or fumes, 

emotion, stress, overexertion, loud or sudden noises, 

motion sickness, low blood sugar, skipped meals, 

tobacco, depression, anxiety, head trauma, hangover, some medications, hormonal changes, and 

bright or flashing lights. Medication overuse or missed 

doses may also cause headaches. In some 50 percent 

of migraine sufferers, foods or ingredients can trigger 

headaches. These include aspartame, caffeine (or 

caffeine withdrawal), wine and other types of alcohol, 

chocolate, aged cheeses, monosodium glutamate, 

some fruits and nuts, fermented or pickled goods, 

yeast, and cured or processed meats. Keeping a 

diet journal will help identify food triggers. 

Caffeine (or caffeine withdrawal) 

is one of many triggers for 

migraine headaches. 

7 
	 	 	 	 	 	 	 	

8 

Who Gets Migraines? Migraines occur in both 

children and adults, but affect adult women three 

times more often than men. There is evidence that 

migraines are genetic, with most migraine sufferers 

having a family history of the disorder. They also 

frequently occur in people who have other medical 

conditions. Depression, anxiety, bipolar disorder, 

sleep disorders, and epilepsy are more common 

in individuals with migraine than in the general 

population. Migraine sufferers—in particular 

those individuals who have pre-migraine symptoms 

referred to as aura—have a slightly increased risk 

of having a stroke. 

Migraine in women often relates to changes in 

hormones. The headaches may begin at the start 

of the first menstrual cycle or during pregnancy. 

Most women see improvement after menopause, 

although surgical removal of the ovaries usually 

worsens migraines. Women with migraine who take 

oral contraceptives may experience changes in the 

frequency and severity of attacks, while women 

who do not suffer from headaches may develop 

migraines as a side effect of oral contraceptives. 

Phases of Migraine. Migraine is divided into four 

phases, all of which may be present during the attack: 

•	 Premonitory symptoms occur up to 24 hours 

prior to developing a migraine. These include 

food cravings, unexplained mood changes 

(depression or euphoria), uncontrollable yawning, fluid retention, or increased urination. 

•	 Aura. Some people will see flashing or bright

lights or what looks like heat waves immediately 

prior to or during the migraine, while others 

may experience muscle weakness or the 

sensation of being touched or grabbed. 
	 	 	 	 	 	

 

•	 Headache. A migraine usually starts gradually

and builds in intensity. It is possible to have 


migraine without head pain.
 

•	 Postdrome (following the headache). Individuals 

are often exhausted or confused following a 

migraine. The postdrome period may last up 

to a day before people feel healthy. 

Types of Migraine. The two major types of 

migraine are: 

•	 Migraine with aura, previously called classic 

migraine, includes visual disturbances and 

other neurological symptoms that appear 

about 10 to 60 minutes before the actual 

headache and usually last no more than an 

hour. Individuals may temporarily lose part 

or all of their vision. The aura may occur 

without headache pain, which can strike at 

any time. Other classic symptoms include 

trouble speaking; an abnormal sensation, 

numbness, or muscle weakness on one side 

of the body; a tingling sensation in the hands 

or face, and confusion. Nausea, appetite loss, Nausea, loss of appetite, and sensitivity to light and increased sensitivity or sound may precede to light, sound, or noise migraine headache. may precede the headache. 

•	 Migraine without aura, or common migraine, 

is the more frequent form of migraine. 

Symptoms include headache pain that occurs 

without warning and is usually felt on one 

side of the head, along with nausea, confusion, 

blurred vision, mood changes, fatigue, and 

increased sensitivity to light, sound, or noise. 

9 
10 

Other types of migraine include: 

•	 Abdominal migraine mostly affects young 

children and involves moderate to severe 

pain in the middle of the abdomen lasting 

1 to 72 hours, with little or no headache. 

Additional symptoms include nausea, vomiting, and loss of appetite. Many children 

who develop abdominal migraine will have 

migraine headaches later in life. 

•	 Basilar-type migraine mainly affects 

children and adolescents. It occurs most 

often in teenage girls and may be associated 

with their menstrual cycle. Symptoms include 

partial or total loss of vision or double vision, 

dizziness and loss of balance, poor muscle 

coordination, slurred speech, a ringing in 

the ears, and fainting. The throbbing pain 

may come on suddenly and is felt on both 

sides at the back of the head. 

•	 Hemiplegic migraine is a rare but severe 

form of migraine that causes temporary 

paralysis—sometimes lasting several days— 

on one side of the body prior to or during 

a headache. Symptoms such as vertigo, a 

pricking or stabbing sensation, and problems 

seeing, speaking, or swallowing may begin 

prior to the headache pain and usually stop 

shortly thereafter. When it runs in families 

the disorder is called familial hemiplegic migraine (FHM). Though rare, at least three 

distinct genetic forms of FHM have been 

identified. These genetic mutations make 

the brain more sensitive or excitable, most 

likely by increasing brain levels of a 

chemical called glutamate. 
•	 Menstrually related migraine affects women 

around the time of their period, although most 

women with menstrually related migraine also 

have migraines at other times of the month. 

Symptoms may include migraine without aura 

(which is much more common during menses 

than migraine with aura), pulsing pain on 

one side of the head, nausea, vomiting, and 

increased sensitivity to sound and light. 

•	 Migraine without headache is characterized 

by visual problems or other aura symptoms, 

nausea, vomiting, and constipation, but without 

head pain. Headache specialists have suggested 

that fever, dizziness, and/or unexplained pain 

in a particular part of the body could also be 

possible types of headache-free migraine. 

•	 Ophthalmoplegic migraine an uncommon 

form of migraine with head pain, along with 

a droopy eyelid, large pupil, and double 

vision that may last for weeks, long after 

the pain is gone. 

•	 Retinal migraine is a condition characterized 

by attacks of visual loss or disturbances in 

one eye. These attacks, like the more common 

visual auras, are usually associated with 

migraine headaches. 

•	 Status migrainosus is a rare and severe type 

of acute migraine in which disabling pain and 

nausea can last 72 hours or longer. The pain 

and nausea may be so intense that sufferers 

need to be hospitalized. 

Migraine Treatment. Migraine treatment is aimed 

at relieving symptoms and preventing additional 

attacks. Quick steps to ease symptoms may include 

napping or resting with eyes closed in a quiet, 

11 
 

12 

darkened room; 

placing a cool 

cloth or ice pack 

on the forehead; 

and drinking 

lots of fluid, 

particularly if 

the migraine is 

accompanied by 

vomiting. Small 

amounts of caffeine may help relieve symptoms 

during a migraine’s early stages. 

Drug therapy for migraine is divided into acute 

and preventive treatment. Acute or “abortive” 

medications are taken as soon as symptoms occur 

to relieve pain and restore function. Preventive 

treatment involves taking medicines daily to 

reduce the severity of future attacks or keep 

them from happening. The U.S. Food and Drug 

Administration (FDA) has approved a variety 

of drugs for these treatment methods.2

 Headache 

drug use should be monitored by a physician, 

since some drugs may cause side effects. 

Acute treatment for migraine may include any of 

the following drugs. 

•	 Triptan drugs increase levels of the neurotransmitter serotonin in the brain. Serotonin 

causes blood vessels to constrict and lowers 

the pain threshold. Triptans—the preferred 

treatment for migraine—ease moderate to 

severe migraine pain and are available as 

tablets, nasal sprays, and injections. 

•	 Ergot derivative drugs bind to serotonin 

receptors on nerve cells and decrease the 

2	 For information about drugs to treat migraine, visit the Food and Drug 

Administration web site at www.fda.gov or call 800-INFO-FDA. 

The primary goals of migraine treatment are to 

relieve symptoms and prevent additional attacks. 

Over-the-counter drugs can ease the pain of less 

severe migraine headaches. 
 

	 	 	

	 	 	 	 	 	

	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

transmission of pain messages along nerve 


fibers. They are most effective during the 


early stages of migraine and are available 


as nasal sprays and injections.
 

•	 Non-prescription analgesics or over-thecounter drugs such as ibuprofen, aspirin, 

or acetaminophen can ease the pain of less 

severe migraine headache. 

•	 Combination analgesics involve a mix of

drugs such as acetaminophen plus caffeine 

and/or a narcotic for migraine that may be 

resistant to simple analgesics. 

•	 Nonsteroidal anti-inflammatory drugs can

reduce inflammation and alleviate pain. 

•	 Nausea relief drugs can ease queasiness

brought on by various types of headache. 

•	 Narcotics are prescribed briefly to relieve

pain. These drugs should not be used to 


treat chronic headaches.
 

Taking headache relief drugs more than three 

times a week may lead to medication overuse 

headache (previously called rebound headache), 

in which the initial headache is relieved temporarily 

but reappears as the drug wears off. Taking more 

of the drug to treat the new headache leads to 

progressively shorter periods of pain relief and 

results in a pattern of recurrent chronic headache. 

Headache pain ranges from moderate to severe 

and may occur with nausea or irritability. It may 

take weeks for these headaches to end once the 

drug is stopped. 

Everyone with migraine needs effective treatment 

at the time of the headaches. Some people with 

frequent and severe migraine need preventive 

13 
	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	

14 

medications. In general, prevention should be 

considered if migraines occur one or more times 

weekly, or if migraines are less frequent but 

disabling. Preventive medicines are also recommended for individuals who take symptomatic 

headache treatment more than 3 times a week. 

Physicians will also recommend that a migraine 

sufferer take one or more preventive medications 

2 to 3 months to assess drug effectiveness, unless 

intolerable side effects occur. 

Several preventive medicines for migraine were initially marketed for conditions other than migraine. 

•	 Anticonvulsants may be helpful for people

with other types of headaches in addition 

to migraine. Although they were originally 

developed for treating epilepsy, these drugs 

increase levels of certain neurotransmitters 

and dampen pain impulses. 

•	 Beta-blockers are drugs for treating high blood

pressure that are often effective for migraine. 

•	 Calcium channel blockers are medications

that are also used to treat high blood pressure 

and help to stabilize blood vessel walls. These 

drugs appear to work by preventing the blood 

vessels from either narrowing or widening, 

which affects blood flow to the brain. 

•	 Antidepressants are drugs that work on different chemicals in the brain; their effectiveness 

in treating migraine is not directly related to 

their effect on mood. Antidepressants may 

be helpful for individuals with other types 

of headaches because they increase the production of serotonin and may also affect levels 

of other chemicals, such as norepinephrine 

and dopamine. The types of antidepressants 
used for migraine treatment include selective 

serotonin reuptake inhibitors, serotonin and 

norepinephrine reuptake inhibitors, and 

tricyclic antidepressants (which are also used 

to treat tension-type headaches). 

Natural treatments for migraine include 

riboflavin (vitamin B2), magnesium, coenzyme 

Q10, and butterbur. 

Non-drug therapy for migraine includes biofeedback and relaxation training, both of which help 

individuals cope with or control the development 

of pain and the body’s response to stress. 

Lifestyle changes that reduce or prevent migraine 

attacks in some individuals include exercising, 

avoiding food and beverages that trigger headaches, 

eating regularly scheduled meals with adequate 

hydration, stopping certain medications, and 

establishing a consistent sleep schedule. Obesity 

increases the risk of developing chronic daily 

headache, so a weight loss program is recommended for obese individuals. 

Tension-type 

Tension-type headache, previously called muscle 

contraction headache, is the most common type of 

headache. Its name indicates the role of stress and 

mental or emotional 

conflict in triggering 

the pain and contracting muscles in the neck, 

face, scalp, and jaw. 

Tension-type headaches 

may also be caused by 

jaw clenching, intense 

work, missed meals, Tension-type headaches—the most common 

type of headache—may feel as if a belt or 

“vice” is being tightened around the head. 

15 
16 

depression, anxiety, or too little sleep. Sleep 

apnea may also cause tension-type headaches, 

especially in the morning. The pain is usually 

mild to moderate and feels as if constant pressure 

is being applied to the front of the face or to the 

head or neck. It also may feel as if a belt is being 

tightened around the head. Most often the pain is 

felt on both sides of the head. People who suffer 

tension-type headaches may also feel overly 

sensitive to light and sound but there is no 

pre-headache aura as with migraine. Typically, 

tension-type headaches usually disappear once 

the period of stress or related cause has ended. 

Tension-type headaches affect women slightly 

more often than men. The headaches usually 

begin in adolescence and reach peak activity in 

the 30s. They have not been linked to hormones 

and do not have a strong hereditary connection. 

There are two forms of tension-type headache: 

Episodic tension-type headaches occur between 

10 and 15 days per month, with each attack lasting from 30 minutes to several days. Although the 

pain is not disabling, the severity of pain typically 

increases with the frequency of attacks. Chronic 

tension-type attacks usually occur more than 

15 days per month over a 3-month period. The 

pain, which can be constant over a period of days 

or months, strikes both sides of the head and is 

more severe and disabling than episodic headache 

pain. Chronic tension headaches can cause sore 

scalps—even combing your hair can be painful. 

Most individuals will have had some form of 

episodic tension-type headache prior to onset 

of chronic tension-type headache. 
 

Depression and anxiety can cause tension-type 

headaches. Headaches may appear in the early 

morning or evening, when conflicts in the office 

or at home are anticipated. Other causes include 

physical postures that strain head and neck muscles 

(such as holding your chin down while reading or 

holding a phone between your shoulder and ear), 

degenerative arthritis of the neck, and temporomandibular joint dysfunction (a disorder of the 

joints between the temporal bone located above 

the ear and the mandible, or lower jaw bone). 

The first step in caring for a tension-type headache 

involves treating any specific disorder or disease 

that may be causing it. For example, arthritis of the 

neck is treated with anti-inflammatory medication 

and temporomandibular joint dysfunction may be 

helped by corrective devices for the mouth and jaw. 

A sleep study may be needed to detect sleep apnea 

and should be considered when there is a history 

of snoring, daytime sleepiness, or obesity. 

A physician may suggest using analgesics, nonsteroidal anti-inflammatory drugs, or antidepressants to 

treat a tension-type headache that is not associated 

with a disease. Triptan drugs, barbiturates (drugs 

that have a relaxing or sedative effect), and ergot 

derivatives may provide relief to people who suffer 

from both migraine and tension-type headache. 

Alternative therapies for chronic tension-type 

headaches include biofeedback, relaxation training, 

meditation, and cognitive-behavioral therapy to 

reduce stress. A hot shower or moist heat applied to 

the back of the neck may ease symptoms of infrequent 

tension headaches. Physical therapy, massage, and 

gentle exercise of the neck may also be helpful. 

17 
 

 

18 

Trigeminal Autonomic Cephalgias 

Some primary headaches are characterized by 

severe pain in or around the eye on one side of 

the face and autonomic (or involuntary) features 

on the same side, such as red and teary eye, 

drooping eyelid, and runny nose. These disorders, 

called trigeminal autonomic cephalgias (cephalgia 

meaning head pain), differ in attack duration 

and frequency, and have episodic and chronic 

forms. Episodic attacks occur on a daily or 

near-daily basis for weeks or months with painfree remissions. Chronic attacks occur on a daily 

or near-daily basis for a year or more with only 

brief remissions. 

Cluster headache—the most severe form of 

primary headache—involves sudden, extremely 

painful headaches that occur in “clusters,” usually 

at the same time of the day and night for several 

weeks. They strike one side of the head, often 

behind or around one eye, and may be preceded 

by a migraine-like aura and nausea. The pain 

usually peaks 5 to 10 minutes after onset and 

continues at that intensity for up to 3 hours. 

The nose and the eye on 

the affected side of the 

face may get red, swollen, 

and teary. Some people 

will experience restlessness and agitation, 

changes in heart rate 

and blood pressure, 

and sensitivity to light, 

sound, or smell. Cluster 

headaches often wake 

people from sleep. 

Cluster headaches involve sudden, extremely painful 

headaches that occur at the same time of the day or 

night. They can be provoked by alcohol, especially red 

wine, and smoking. 
Cluster headaches generally begin between the 

ages of 20 and 50 but may start at any age, occur 

more often in men than in women, and are more 

common in smokers than in nonsmokers. The 

attacks are usually less frequent and shorter 

than migraines. It’s common to have 1 to 3 cluster 

headaches a day with 2 cluster periods a year, 

separated by months of freedom from symptoms. 

The cluster periods often appear seasonally, 

usually in the spring and fall, and may be mistaken for allergies. A small group of people 

develop a chronic form of the disorder, which 

is characterized by bouts of headaches that can 

go on for years with only brief periods (1 month 

or less) of remission. Cluster headaches occur 

more often at night than during the day, suggesting they could be caused by irregularities in the 

body’s sleep-wake cycle. Alcohol (especially red 

wine) and smoking can provoke attacks. Studies 

show a connection between cluster headache and 

prior head trauma. An increased familial risk 

of these headaches suggests that there may be 

a genetic cause. 

Treatment options include oxygen therapy—in 

which pure oxygen is breathed through a mask 

to reduce blood flow to the brain—and triptan 

drugs. Certain antipsychotic drugs, calciumchannel blockers, and anticonvulsants can reduce 

pain severity and frequency of attacks. In extreme 

cases, electrical stimulation of the occipital nerve 

to prevent nerve signaling or surgical procedures 

that destroy or cut certain facial nerves may 

provide relief. 

19 
20 

Paroxysmal hemicrania is a rare form of primary 

headache that usually begins in adulthood. Pain 

and related symptoms may be similar to those felt 

in cluster headaches, but with shorter duration. 

Attacks typically occur 5 to 40 times per day, 

with each attack lasting 2 to 45 minutes. Severe 

throbbing, claw-like, or piercing pain is felt on 

one side of the face—in, around, or behind the 

eye and occasionally reaching to the back of the 

neck. Other symptoms may include red and watery 

eyes, a drooping or swollen eyelid on the affected 

side of the face, and nasal congestion. Individuals 

may also feel dull pain, soreness, or tenderness 

between attacks or increased sensitivity to light on 

the affected side of the face. Paroxysmal hemicrania has two forms: chronic, in which individuals 

experience attacks on a daily basis for a year or 

more, and episodic, in which the headaches may 

stop for months or years before recurring. Certain 

movements of the head or neck, external pressure 

to the neck, and alcohol use may trigger these 

headaches. Attacks occur more often in women 

than in men and have no familial pattern. 

The nonsteroidal anti-inflammatory drug indomethacin can quickly halt the pain and related 

symptoms of paroxysmal hemicrania, but symptoms recur once the drug treatment is stopped. 

Non-prescription analgesics and calcium-channel 

blockers can ease discomfort, particularly if taken 

when symptoms first appear. 

SUNCT (Short-lasting, Unilateral, Neuralgiform 

headache attacks with Conjunctival injection 

and Tearing) is a very rare type of headache with 

bursts of moderate to severe burning, piercing, or 

throbbing pain that is usually felt in the forehead, 
 

eye, or temple on one side of the head. The pain 

usually peaks within seconds of onset and may 

follow a pattern of increasing and decreasing 

intensity. Attacks typically occur during the 

day and last 

from 5 seconds SUNCT headaches cause 

to 4 minutes per bursts of burning, piercing, 

episode. Individu­ or throbbing pain usually in

als generally have the forehead, eye, or temple five to six attacks on one side of the head. per hour and are 

pain-free between 

attacks. This primary headache is slightly more 

common in men than in women, with onset usually 

after age 50. SUNCT may be episodic, occurring 

once or twice annually with headaches that remit 

and recur, or chronic, lasting more than 1 year. 

Symptoms include reddish or bloodshot eyes (conjunctival injection), watery eyes, stuffy or runny 

nose, sweaty forehead, puffy eyelids, increased 

pressure within the eye on the affected side of the 

head, and increased blood pressure. 

SUNCT is very difficult to treat. Anticonvulsants 

may relieve some of the symptoms, while anesthetics 

and corticosteroid drugs can treat some of the 

severe pain felt during these headaches. Surgery 

and glycerol injections to block nerve signaling 

along the trigeminal nerve have poor outcomes 

and provide only temporary relief in severe cases. 

Doctors are beginning to use deep brain stimulation 

(involving a surgically implanted battery-powered 

electrode that emits pulses of energy to surrounding 

brain tissue) to reduce the frequency of attacks in 

severely affected individuals. 

21 
22 

Miscellaneous Primary Headaches 

Other headaches that are not caused by other 

disorders include: 

Chronic daily headache refers to a group of 

headache disorders that occur at least 15 days 

a month during a 3-month period. In addition to 

chronic tension-type headache, chronic migraine, 

and medication overuse headache, these headaches 

include hemicrania continua and new daily persistent headache. Individuals feel constant, mostly 

moderate pain throughout the day on the sides or 

top of the head. They may also experience other 

types of headache. Adolescents and adults may 

experience chronic daily headaches. In children, 

stress from school and family activities may 

contribute to these headaches. 

•	 Hemicrania continua is marked by continuous, 

fluctuating pain that always occurs on the same 

side of the face and head. The headache may 

last from minutes to days and is associated 

with symptoms including tearing, red and 

irritated eyes, sweating, stuffy or runny nose, 

and swollen and drooping eyelids. The pain 

may get worse as the headache progresses. 

Migraine-like symptoms include nausea, 

vomiting, and sensitivity to light and sound. 

Physical exertion and alcohol use may increase 

headache severity. The disorder is more common in women than in men and its cause is 

unknown. Hemicrania continua has two forms: 

chronic, with daily headaches, and remitting 

or episodic, in which headaches may occur 

over a period of 6 months and are followed by 

a pain-free period of weeks to months before 

recurring. Most individuals have attacks of 
increased pain 3 to 5 times per 24-hour cycle. 

The nonsteroidal anti-inflammatory drug 

indomethacin usually provides rapid relief 

from symptoms. Corticosteroids may also 

provide temporary relief from some symptoms. 

•	 New Daily Persistent Headache (NDPH), 

previously called chronic benign daily headache, is known for its constant daily pain that 

ranges from mild to severe. Individuals can 

often recount the exact date and time that the 

headache began. Daily headaches can occur 

for more than 3 months (and sometimes years) 

without lessening or ending. Symptoms include 

an abnormal sensitivity to light or sound, 

nausea, lightheadedness, and a pressing, 

throbbing, or tightening pain felt on both sides 

of the head. NDPH occurs more often in women 

than in men. Most sufferers do not have a prior 

history of headache. NDPH may occur spontaneously or following infection, medication use, 

trauma, high spinal fluid pressure, or other 

condition. The disorder has two forms: one 

that usually ends on its own within several 

months and does not require treatment, and 

a longer-lasting form that is difficult to treat. 

Muscle relaxants, antidepressants, and 

anticonvulsants may provide some relief. 

Primary stabbing headache, also known as “ice 

pick” or “jabs and jolts” headache, is characterized by intense piercing pain that strikes without 

warning and generally lasts 1 to 10 seconds. The 

stabbing pain usually occurs around the eye but 

may be felt in multiple sites along the trigeminal 

nerve. Onset typically occurs between 45 and 

50 years of age. Some individuals may have only 

23 
 

24 

one headache per year while others may have 

multiple headaches daily. Most attacks are spontaneous but headaches may be triggered by sudden 

movement, bright lights, or emotional stress. 

Primary stabbing headache occurs most often in 

people who have migraine, hemicrania continua, 

tension-type, or cluster headaches. The disorder 

is hard to treat, because each attack is extremely 

short. Indomethacin and other headache preventive medications can relieve pain in people who have 

multiple episodes of primary stabbing headache. 

Primary exertional headache may be brought on 

by fits of coughing or sneezing or intense physical 

activity such as running, basketball, lifting weights, 

or sexual activity. The headache begins at the onset 

of activity. Pain rarely lasts more than several 

minutes but can last up to 2 days. Symptoms may 

include nausea and vomiting. This type of headache 

is typically seen in individuals who have a family 

history of migraine. Warm-up exercises prior to the 

physical activity can help prevent the headache and 

indomethacin can relieve the headache pain. 

Hypnic headache, previously called “alarm-clock” 

headache, awakens people mostly at night. Onset is 

usually after age 50. Hypnic headache may occur 

15 or more times per 

month, with no known 

trigger. Bouts of mild 

to moderate throbbing 

pain usually last from 

15 minutes to 3 hours 

after waking and are 

most often felt on both 

sides of the head. Other 

symptoms include 

nausea or increased 

Hypnic or “alarm clock” headaches usually 

awaken people at night with bouts of mild 

to moderate throbbing pain lasting from 

15 minutes to 3 hours. 
 

 

 

 

sensitivity to sound or light. Hypnic headache 

may be a disorder of rapid eye movement (REM) 

sleep as the attacks occur most often during 

dreaming. Both men and women are affected 

by this disorder, which is usually treated with 

caffeine, indomethacin, or lithium. 

If you’ve ever eaten or inhaled a cold substance 

very fast, you may have had what’s called an ice 

cream headache (sometimes called “brain freeze”). 

This headache happens when cold materials such as 

cold drinks or ice cream hit the warm roof of your 

mouth. Local blood vessels constrict to reduce the 

loss of body heat and then relax and allow the blood 

flow to increase. The resulting burst of pain lasts 

for about 5 minutes. Ice cream headache is more 

common in individuals who have migraine. The pain 

stops once the body adapts to the temperature change. 

Secondary headache disorders are caused by an 

underlying illness or condition that affects the brain. 

Secondary headaches are usually diagnosed based 

on other symptoms that occur concurrently and the 

characteristics of the headaches. Some of the more 

serious causes of secondary headache include: 

Brain tumor. A tumor that is growing in the brain 

can press against nerve tissue and pain-sensitive 

blood vessel walls, disrupting communication 

between the brain and the nerves or restricting the 

supply of blood to the brain. Headaches may develop, 

worsen, become more frequent, or come and go, 

often at irregular periods. Headache pain may worsen 

when coughing, changing posture, or straining, and 

may be severe upon waking. Treatment options 

include surgery, radiation therapy, and chemotherapy. However, the vast majority of individuals with 

headache do not have brain tumors. 

25 
	 	 	 	 	

26 

Disorders of blood vessels in the brain, including 

stroke. Several disorders associated with blood vessel formation and activity can cause headache. Most 

notable among these conditions is stroke. Headache 

itself can cause stroke or accompany a series of 

blood vessel disorders that can cause a stroke. 

There are two forms of 

Secondary headaches are stroke. A hemorrhagic caused by underlying stroke occurs when 

illnesses or conditions an artery in the brain that affect the brain. bursts, spilling blood 

into the surrounding 

tissue. An ischemic stroke occurs when an artery 

supplying the brain with blood becomes blocked, 

suddenly decreasing or stopping blood flow and 

causing brain cells to die. 

Hemorrhagic Stroke 

A hemorrhagic stroke is usually associated with 

disturbed brain function and an extremely painful 

headache that develops suddenly and may worsen 

with physical activity, coughing, or straining. 

Headache conditions associated with hemorrhagic 

stroke include: 

•	 A subarachnoid hemorrhage is the rupture of

a blood vessel located within the subarachnoid 

space—a fluid-filled space between layers of 

connective tissue (meninges) that surround the 

brain. The first sign of a subarachnoid hemorrhage is typically a severe headache with a 

split-second onset and no known cause. 

Neurologists call this a thunderclap headache. 

Pain may also be felt in the neck and lower 

back. This sudden flood of blood can contaminate the cerebrospinal fluid that flows within 
	 	 	 	

	 	 	 	 	 	

 

the spaces of the brain and cause extensive 

damage throughout the brain. 

•	 Intracerebral hemorrhage is usually associated

with severe headache. Several conditions can 

render blood vessels in the brain prone to rupture and hemorrhaging. Chronic hypertension 

can weaken the blood vessel wall. Poor blood 

clotting ability due to blood disorders or bloodthinning medications like warfarin further 

increase the risk of bleeding. And some venous 

strokes (caused by clots in the brain’s veins) 

often cause bleeding into the brain. At risk are 

mothers in the post-partum period and persons 

with dehydration, cancer, or infections. 

•	 An aneurysm is the abnormal ballooning

of an artery that causes the artery wall to 

weaken. A ruptured cerebral aneurysm can 

cause hemorrhagic stroke and a sudden, 

incredibly painful headache that is generally 

different in severity and intensity from other 

headaches individuals may have experienced. 

Individuals usually describe the thunderclaplike headache as “the worst headache of my 

life.” There may be loss of consciousness and 

other neurological features. “Sentinel” or 

sudden warning headaches sometimes occur 

from an aneurysm that leaks prior to rupture. 

Cerebral aneurysms that have leaked or ruptured are life-threatening and require emergency 

medical attention. Not all aneurysms burst, 

and people with very small aneurysms may 

be monitored to detect any growth or onset of 

symptoms. Treatment options include blocking 

the flow of blood to the aneurysm surgically 

(intra-arterial) and catheter techniques to 

fill the aneurysm with coils or balloons. 

27 
	 	 	 	 	 	 	 	

28 

•	 Arteriovenous malformation (AVM), an abnormal 

tangle of arteries and veins in the brain, causes 

headaches that vary in frequency, duration, 

and intensity as vascular malformations press 

on and displace normal tissue or leak blood into 

surrounding tissue. A headache consistently 

affecting one side of the head may be closely 

linked to the site of an AVM (although most 

one-sided headaches are caused by primary 

headache disorders). Symptoms may include 

seizures and hearing pulsating noises. Treatment options include decreasing blood flow 

to and from the malformation by injecting 

particles or glue, or through focused 

radiotherapy or surgery. 

Ischemic Stroke 

Headache that accompanies ischemic stroke can 

be caused by several problems with the brain’s 

vascular system. Headache is prominent in 

individuals with clots in the brain’s veins. Head 

pain occurs on the side of the brain in which the 

clot blocks blood flow and is often felt in the 

eyes or on the side of the head. Conditions of 

ischemic stroke that can cause headache include: 

•	 Arterial dissection is a tear within an artery

that supplies the brain with blood flow. The 

most common dissection occurs in the carotid 

artery in the neck, with head pain on the 

same side of the body where the tear occurs. 

Vertebral artery dissection causes pain in the 

rear upper part of the neck. Cervical artery 

dissection can lead to stroke or transient 

ischemic attacks (strokes that last only a few 

minutes but signal a subsequent, more severe 

stroke). They are usually caused by neck 
	 	 	 	 	

 

 

strain, i.e., trauma, chiropractic manipulation, 

sports injuries, or even pronounced bending 

of the head backwards over a sink for hair 

washing (“beauty parlor stroke”). Immediate 

medical attention can be lifesaving. 

•	 Vascular inflammation can cause the buildup

of plaque, which can lead to ischemic stroke. 

Cerebral vasculitis, an inflammation of the 

brain’s blood vessel system, may cause headache, 

stroke, and/or progressive cognitive decline. 

Severe headache attributed to a chronic 

inflammatory disease of blood vessels on the 

outside of the head, called giant cell arteritis 

(previously known as temporal arteritis), 

usually affects people older than age 60. It 

also causes muscle pain and tenderness in the 

temple area. Individuals also may experience 

temporary, followed by permanent, loss of 

vision on one or both eyes, pain with chewing, 

a tender scalp, muscle aches, depression, and 

fatigue. Corticosteroids are typically used 

to treat vascular inflammation and can 

prevent blindness. 

Exposure to a substance or its withdrawal. 

Headaches may result from toxic states such as 

drinking alcohol, following carbon monoxide poisoning, or from exposure to toxic chemicals and metals, 

cleaning products or solvents, and pesticides. In the 

most severe cases, rising toxin levels can cause a 

pulsing, throbbing headache that, if left untreated, 

can lead to systemic poisoning, organ failure, and 

permanent neurological damage. These headaches 

are usually treated by identifying and removing the 

cause of the toxic buildup. The withdrawal from 

certain medicines or caffeine after frequent or 

excessive use can also cause headaches. 

29 
 

 

 

 

 

30 

Head injury. Headaches are often a symptom of 

a concussion or other head injury. The headache 

may develop either immediately or months after a 

blow to the head, with pain felt at the injury site or 

throughout the head. Emotional disturbances may 

worsen headache pain. In most cases, the cause of 

post-traumatic headache is unknown. Sometimes 

the cause is ruptured blood 

Headaches associated with vessels, which result in an 

head trauma may develop accumulation of blood called 

immediately or months a hematoma. This mass of 

after a blow to the head. blood can displace brain 

tissue and cause headaches 

as well as weakness, confusion, memory loss, and 

seizures. Hematomas can be drained surgically to 

produce rapid relief of symptoms. Bleeding between 

the dura (the outermost layer of the protective 

covering of the brain) and the skull, called epidural 

hematoma, usually occurs minutes to hours after a 

skull fracture and is especially dangerous. Bleeding 

between the brain and the dura, called subdural hematoma, is frequently associated with a dull, persistent ache on one side of the head. Nausea, vomiting, 

and mild disturbance of brain function also occur. 

Subdural hematoma may occur after head trauma 

but also occurs spontaneously in elderly persons or 

in individuals taking anticoagulant medications. 

Increased intracranial pressure. A growing tumor, 

infection, or hydrocephalus (an extensive buildup 

of cerebrospinal fluid in the brain) can raise pressure in the brain and compress nerves and blood 

vessels, causing headaches. Hydrocephalus is most 

often treated with the surgical placement of a shunt 

system that diverts the fluid to a site elsewhere in 

the body, where it can be absorbed as part of the 

circulatory process. Headache attributed to idiopathic 
 

 

 

 

intracranial hypertension, previously known as 

pseudotumor cerebri (meaning “false brain tumor”), 

is associated with severe headache. It can be caused 

by clotting in the major cerebral veins or certain 

medications (some antibiotics, withdrawal of corticosteroids, human growth hormone replacement, 

and vitamin A and related compounds). It is most 

commonly seen in young, overweight females. Diagnosis usually requires a spinal fluid examination to 

document the high pressure and the rapid resolution 

of headache after the spinal fluid is removed. Although 

called benign, the condition may lead to visual loss 

if left untreated. Weight loss, ending the use of the 

drug suspected of causing the problem, and diuretic 

treatment can help relieve the pressure. 

Inflammation from meningitis, encephalitis, and 

other infections. Inflammation from infections can 

harm or destroy nerve cells and cause dull to severe 

headache pain, brain damage, or stroke, among 

other conditions. Inflammation of the brain and 

spinal cord (meningitis and encephalitis) requires 

urgent medical attention. Diagnosis and identification of the infection usually requires examination 

and culture of a sample of the cerebrospinal fluid. 

Treatment options include antibiotics, antiviral or 

antifungal drugs, corticosteroids, pain medications 

and sedatives, and anticonvulsants. Headaches 

may also occur with a fever or a flu-like infection. 

A headache may accompany a bacterial infection 

of the upper respiratory tract that spreads to and 

inflames the lining of the sinus cavities. When one or 

more of the cavities fills with fluid from the inflammation, the result is constant but dull facial pain 

and tenderness that worsens with straining or 

head movements. Treatment includes antibiotics, 

analgesics, and decongestants. Sinus infections 

do not generally cause chronic headaches. 

31 
 

32 

“Sinus” headaches occur when one or more of the 

sinus cavities fills with fluid caused by inflammation 

resulting in constant dull facial pain and tenderness. 

Seizures. Migraine-like 

headache pain may occur 

during or after a seizure. 

Moderate to severe headache pain may last for 

several hours and worsen 

with sudden movements of 

the head or when sneezing, 

coughing, or bending. 

Other symptoms may 

include nausea, vomiting, 

fatigue, increased sensitivity to light or sound, and 

vision problems. 

Spinal fluid leak. About one-fourth of people 

who undergo a lumbar puncture (which involves 

a small sampling of the spinal fluid being removed 

for testing) develop a headache due to a leak of 

cerebrospinal fluid following the procedure. Since 

the headache occurs only when the individual 

stands up, the “cure” is to lie down until the headache runs its course—anywhere from a few hours 

to several days. Severe post-dural headaches 

may be treated by injecting a small amount of 

the individual’s blood into the lower back to 

stop the leak (called an epidural blood patch). 

Occasionally spinal fluid leaks spontaneously, 

causing this “low pressure headache.” 

Structural abnormalities of the head, neck and 

spine. Headache pain and loss of function may be 

triggered by structural abnormalities in the head 

or spine, restricted blood flow through the neck, 

irritation to nerves anywhere along the path from 

the spinal cord to the brain, or stressful or awkward 
positions of the head and neck. Surgery is the only 

treatment available to correct the condition or 

halt the progression of damage to the central 

nervous system. Medications may ease the pain. 

Cerivcogenic headaches are caused by structural 

irregularities in either the head or neck. In a 

chiari malformation, the back of the skull is too 

small for the brain. This forces a part of the brain 

to block the normal flow of spinal fluid and press 

on the brain stem. Chiari malformations are present at birth but may not cause symptoms until later 

in life. Common symptoms include dizziness, muscle 

weakness, vision problems, and headache that 

worsens with coughing or straining. Syringomyelia, 

a fluid-filled cyst within the spinal cord, can cause 

pain, numbness, weakness, and headaches. 

Trigeminal neuralgia. The trigeminal nerve 

conducts sensations to the brain from the upper, 

middle, and lower portions of the face, as well as 

inside the mouth. The presumed cause of trigeminal 

neuralgia is a blood vessel pressing on the nerve as 

it exits the brain stem, but other causes have been 

described. Symptoms include headache and intense 

shock-like or stabbing pain that comes on suddenly 

and is typically felt on one side of the jaw or cheek. 

Muscle spasms may occur on the affected side of 

the face. The pain may occur spontaneously or 

be triggered by touching the cheek, as happens 

when shaving, washing, or applying makeup. The 

pain also may occur when eating, drinking, talking, 

smoking, or brushing teeth, or when the face is 

exposed to wind. Treatment options include anticonvulsants, antidepressants, and surgery to 

block pain signaling to the brain. 

33 
 

 

 

34 

Children and Headache 

Headaches are common in children. Headaches 

that begin early in life can develop into migraines 

as the child grows older. Migraines in children or 

adolescents can develop into tension-type headaches 

at any time. In contrast to adults with migraine, 

young children often feel migraine pain on both 

sides of the head and have headaches that usually 

last less than 2 hours. Children may look pale and 

appear restless or irritable before and during an 

attack. Other children may become nauseous, 

lose their appetite, or feel pain elsewhere in the 

body during the headache. 

Headaches in children can be caused by a number 

of triggers, including emotional problems such 

as tension between family members, stress from 

school activities, weather changes, irregular eating 

and sleep, dehydration, and 

certain foods and drinks. 

Of special concern among 

children are headaches that 

occur after head injury or 

those accompanied by rash, 

fever, or sleepiness. 

It may be difficult to identify 

the type of headache because 

children often have problems 

describing where it hurts, 

how often the headaches 

occur, and how long they 

last. Asking a child with a 

headache to draw a picture of 

where the pain is and how it feels can make it easier 

for the doctor to determine the proper treatment. 

Headaches in children are common and can 

be caused by a number of triggers, including 

emotional problems, stress, weather changes, 

irregular sleep and eating, dehydration, and 

certain foods and drinks. 
 

Migraine in particular is often misdiagnosed in 

children. Parents and caretakers sometimes have 

to be detectives to help determine that a child has 

a migraine. Clues to watch for include sensitivity 

to light and noise, which may be suspected when a 

child refuses to watch television or use the computer, 

or when the child stops playing to lie down in a 

dark room. Observe whether or not a child is able 

to eat during a headache. Very young children 

may seem cranky or irritable and complain of 

abdominal pain (abdominal migraine). 

Headache treatment in children and teens usually 

includes rest, fluids, and over-the-counter pain 

relief medicines. Always consult with a physician 

before giving headache medicines to a child. Most 

tension-type headaches in children can be treated 

with over-the-counter medicines that are marked 

for children with usage guidelines based on the 

child’s age and weight. Headaches in some children 

may also be treated effectively using relaxation/ 

behavioral therapy. Children with cluster headache 

may be treated with oxygen therapy early in the 

initial phase of the attacks. 

Headache and Sleep Disorders 

Headaches are often a secondary symptom of a 

sleep disorder. For example, tension-type headache is regularly seen in persons with insomnia or 

sleep-wake cycle disorders. Nearly three-fourths of 

individuals who suffer from narcolepsy complain 

of either migraine or cluster headache. Migraines 

and cluster headaches appear to be related to the 

number of and transition between rapid eye movement (REM) and other sleep periods an individual 

35 
 

 

 

36 

has during sleep. Hypnic headache awakens individuals mainly at night but may also interrupt 

daytime naps. Reduced oxygen levels in people with 

sleep apnea may trigger early morning headaches. 

Getting the proper amount of sleep can ease headache pain. Generally, sleeping too little or too much 

can worsen headaches, as can overuse of sleep 

medicines. Daytime naps often reduce deep sleep at 

night and can produce headaches in some adults. 

Some sleep disorders and secondary headaches 

are treated using antidepressants. Check with a 

doctor before using over-the-counter medicines 

to ease sleep-associated headaches. 

Coping with Headache 

Headache treatment is a partnership between you 

and your doctor, and honest communication is 

essential. Finding a quick fix to your headache 

may not be possible. It may 

take some time for your 

doctor or specialist to 

determine the best course 

of treatment. Avoid using 

over-the-counter medicines 

more than twice a week, as 

they may actually worsen 

headache pain and the 

frequency of attacks. Visit 

a local headache support 

group meeting (if available) to learn how others disabling. This drawing vividly illustrates 

with headache cope with how devastating headache pain can be. 

Learning to cope with headache pain their pain and discomfort. and discomfort by gaining control over 

Relax whenever possible your headache, stress, and emotions 

will make you feel better and help you to ease stress and related 

resume daily activities. 

Headache pain can range from mild to 
 

 

symptoms, get enough sleep, regularly perform aerobic 

exercises, and eat a regularly scheduled and healthy 

diet that avoids food triggers. Gaining more control 

over your headache, stress, and emotions will make 

you feel better and let you embrace daily activities 

as much as possible. 

What Research is Being Done? 

Several studies either conducted or supported by 

the National Institute of Neurological Disorders and 

Stroke (NINDS), a part of the National Institutes 

of Health, are revealing much about the headache 

process and may lead to new treatments or perhaps 

ways to block debilitating headache pain. Studies 

by other investigators are adding insight to headache etiology and treatment. 

Understanding Headache Mechanisms and 

Underlying Causes 

The molecular basis for migraine headaches 

and the aura associated with certain migraines 

is uncertain. One multi-faceted research study 

is examining how migraine with aura may affect 

metabolism and neurophysiological function. 

Investigators are also studying if particular regions 

of the visual cortex are unusually susceptible to the 

events in the brain that cause the aura. Another 

study component is investigating what happens at 

the beginning of a headache and how changes in the 

brain’s meninges may lead to vascular and trigeminal nerve stimulation associated with the painful 

part of a migraine headache. Results may provide 

a greater understanding of migraine and assist the 

development of new therapies. 

37 
 

 

 

 

 

 

 

 

 

38 

Mast cells, which are part of the immune system 

and are involved in the inflammatory allergic 

response, are activated in some chronic pain 

conditions, including headache. Researchers are 

examining the possibility of a relationship between 

the mast cells’ anti-analgesic properties and their 

proximity to and enhanced activation of nerve 

fiber endings that receive and transmit pain signals 

(nociceptors). Mast cells may release substances 

that activate nociceptive nerve cells that transmit 

signals from the linings of the skull and its blood 

vessels. Findings that link mast cell activation to 

headache pain may identify drug targets that 

could lead to new analgesics for headache and 

other pain syndromes. 

Cortical spreading depression (CSD) is a process 

in migraine with aura in which a wave of increased 

brain activity, followed by decreased activity, slowly 

spreads along the brain’s surface. The wave of brain 

activity often travels across the part of the brain 

that processes vision and corresponds to the typical 

visual aura of migraine. Research has shown that 

migraines with aura may be associated with tiny areas 

of stroke-like brain damage caused by a short-term 

drop in oxygen levels (associated with the CSD) 

which prevents normal cell function and swelling in 

the brain’s nerve cells. Animal studies have shown 

that CSD also irritates the trigeminal nerve, causing 

it to transmit pain signals and trigger inflammation 

in the membranes that surround the brain. CSD 

inhibiting drugs such as tonabersat are being tested 

in clinical trials for their usefulness in treating 

migraine and other neurological diseases. Other 

investigators hope to build on initial results showing 

that estrogen withdrawal makes it easier for CSD to 

occur in the brains of animals, which may explain 
 

 

 

the contribution of estrogen fluctuation to menstrual migraines. 

This research may result in a 

better understanding of how a 

migraine starts in the brain and 

offer new methods of treatment 

by interrupting this process and 

preventing the migraine. 

Cutaneous allodynia is the feeling 

of pain or unpleasant sensations 

in response to normally nonpainful stimuli, such as light touch. 

Researchers are investigating why 

it is present on the head or face 

in people with cluster headaches, to better understand neurological changes that occur with these 

headaches. Similar research is looking at why some 

people with migraines have more than the typical 

restricted allodynia that affects a particular area 

of the head predicted by the headache (for example, 

on the same side of the face as the migraine pain). 

Individuals with extended allodynia may experience 

unpleasant sensations on the side of the face opposite 

the headache pain or even on their feet. Previous 

studies have shown that sensitized nociceptors 

in the brain’s coverings are involved in the throbbing pain of migraine and that other sensitized 

neurons found deeper in the brain are involved 

with restricted allodynia, but it is not certain which 

cells are responsible for extended allodynia. Future 

studies will explore whether nerve cells in the thalamus (which is involved in relaying signals between 

the brain and the body) become more sensitive as 

a result of the headache pain and cause extended 

allodynia. Findings may offer a better understanding of how the nervous system changes and becomes 

Scientists are conducting studies 

to reveal more information about 

the headache process, which may 

lead to new treatments or ways to 

block debilitating headache pain. 

39 
40 

more sensitive after repeated stimulation, 

resulting in chronic pain. 

Social and other factors may impact headache. 

Researchers are examining how race and psychiatric conditions are related to headache severity, 

quality of life, the ability to reliably follow a 

treatment program, and treatment response in 

people with migraines, tension-type headache, 

substance abuse headache, or cluster headache. 

Genetics of Headache 

Genetics may contribute to a predisposition for 

migraines. Most migraine sufferers have a family 

member with migraine. Researchers are studying 

the activity of different genes to see if they make 

some people more likely to have migraines. One 

strategy is to test for a gene in several families 

having members with migraine and then determine if the gene is related to migraine in a 

broader population. 

In April 2008, researchers at the University of 

Helsinki reported significant evidence for linkage 

between a gene variant on a specific site on chromosome 10q22-q23 and susceptibility to common 

types of migraine. The findings were from a study 

of 1,675 migraine sufferers or their close relatives 

from 210 Finnish and Australian migraine families. 

Another study replicated the findings in the two 

populations and also showed that the site was 

particularly linked to female migraine sufferers. 

Although it has been known for some time that 

genetic factors shared by family members make 

people more susceptible to migraines, this study 

is the first to identify convincingly a specific gene 

locus for common forms of migraine. 
 

 

 

Currently under investigation are gene expression 

patterns (signs of changes in gene activity) in the 

blood of individuals during migraine attacks and 

among individuals with chronic daily headaches. 

Preliminary studies show that children with acute 

migraines and chronic daily headaches have specific 

similar gene expression profiles in their blood that 

are different from healthy individuals and from 

children with other non-related neurological diseases. Researchers are exploring differences in 

gene expression profiles among individuals who 

respond to different types of headache drugs. 

Study results may indicate a molecular genomic 

approach using blood samples to detect genes 

that may be activated during headaches and 

identify which drugs are best used for each 

person with migraines. 

Scientists are exploring the role of the calcitonin 

gene-related peptide (CGRP) in migraines. Levels 

of the CGRP molecule, which is involved in sending 

signals between neurons, increase during migraine 

attacks and revert to normal when the pain resolves. 

Researchers plan to use CGRP as a model and then 

to use functional magnetic resonance imaging to 

estimate the pain response in the central nervous 

system. Evidence from individuals with familial 

hemiplegic migraine (FHM) with known mutations 

indicates that migraine pathways in FHM may be 

different from normal migraine. Investigators 

are also measuring levels of CGRP during the 

premonitory, mild, moderate, and severe phases 

of a single migraine compared to the baseline level 

when individuals are pain-free. The fluctuations 

of CGRP during the migraine process will help 

to define its role in migraine pain and may offer 

new opportunities for acute treatment. 

41 
 

 

 

 

 

 

42 

Migraine in older adults is sometimes 

triggered by sleep changes. 

Researchers are studying the 

role of one drug in reducing the 

number of migraines. 

Clinical Studies in Headache Management 

A major focus of headache research is the development of new drugs and other treatment options. 

Several drug studies seek to identify new drugs to 

treat various headache disorders and to find safer, 

more effective doses for medications already being 

used. Other research is aimed at identifying receptors or drug targets to stop the process of migraine 

aura in the brain. 

Results of three randomized, placebo-controlled 

clinical trials show the drug topiramate is effective, 

safe, and generally well-tolerated for treating chronic 

migraine. Experts agree that treatment with combinations of preventive agents offers maximum relief 

for the majority of individuals with chronic migraine. 

An NINDS-funded clinical trial is examining the 

effectiveness and safety of the drug propranolol 

combined with topiramate in reducing the frequency 

of chronic migraine in 250 participants who will be randomly selected 

to receive treatment with both 

drugs or topiramate and placebo. 

Sleep plays an important role in 

migraine. Migraine in older adults 

is sometimes triggered by sleep 

changes; regulating their sleep may 

lessen the frequency of migraine. 

Younger migraine sufferers often 

report migraine relief after sleep. 

Researchers are studying the use 

of the drug ramelteon, which is approved by the U.S. Food and Drug 

Administration for insomnia, in 

reducing the number of migraines 

over a 12-week period. 
 

 

Headache is the most common symptom after a 

closed head injury, and it can last for more than 

2 months in 60 percent of affected individuals. 

Unfortunately, individuals with chronic posttraumatic headaches also have cognitive and 

behavioral problems, and many drugs currently 

used to treat the headaches also have a negative 

influence on cognition. Scientists are testing different drugs, such as naratriptan (which acts like a 

neurotransmitter) and galantamine (used to treat 

Alzheimer’s disease), to treat both the headache 

and cognitive disturbances in individuals with 

chronic post-traumatic headaches. 

Non-pharmaceutical Approaches to 

Treatment and Prevention 

Historically, very little research has been done 

on children with headaches. A variety of headache 

education and drug and/or behavioral management 

techniques are aimed at improving headache treatment and prevention in children and adolescents. 

Scientists are testing the effectiveness of combined 

pain coping skills (including age appropriate biofeedback, muscle relaxation techniques, imagery, 

activity pacing, and the use of calming techniques) 

and the drug amitriptyline in reducing headache 

frequency, intensity, and depressive symptoms in 

youth ages 10 to 17 years. Additional studies include 

the use of alternative approaches such as yoga to 

decrease headache in adolescents, a modified diet 

to treat chronic daily headache in teenagers, and 

programs designed to teach very young children 

how to understand and self-manage their headaches. 

Craniosacral therapy (CST) involves gentle 

massaging of the neck, head, and spine to release 

constraints in tissue in the head and around the 

43 
 

 

44 

spine. Limited preliminary data shows significant, 

sustained benefit of CST in a small group of individuals with migraine. Future research will gather data 

on the usefulness of CST in preventing migraines and 

examine the feasibility of a larger, randomized trial. 

Electrical stimulation of the occipital nerve has 

effectively eased the symptoms of painful chronic 

headache conditions such as cluster headache as 

well as hard to treat migraine in small clinical studies. 

A tiny battery-powered rechargeable electrode, 

surgically implanted near the occipital nerve, sends 

continuous energy pulses to the nerve to ease pain. 

The use of this non-drug treatment in reducing 

migraine frequency, intensity, and effect on quality 

of life is being tested in larger clinical trials. 

Where Can I Find More Information? 

The National Institute of Neurological Disorders 

and Stroke is the Federal government’s leading 

supporter of biomedical research on brain and 

nervous system disorders, including headache. 

The NINDS conducts research in its own laboratories at the National Institutes of Health in 

Bethesda, Maryland, and supports research at 

institutions nationwide. For the latest information 

about headache and other neurological disorders, 

contact the Institute’s Brain Resources and 

Information Network (BRAIN) at: 

BRAIN 

P.O. Box 5801 


Bethesda, MD 20824 


301-496-5751 


800-352-9424 


www.ninds.nih.gov 
A listing of clinical trials involving headache 

research can be found at http://ClinicalTrials.gov, 

an easy-to-use Web site that provides regularly 

updated information about federally and privately 

supported clinical trials for a wide range of neurological and other disorders and conditions. 

A number of private organizations offer a variety 

of services and information that can help those 

affected by headache. They include: 

American Headache Society 

Committee for Headache Education (ACHE) 

19 Mantua Road 

Mt. Royal, NJ 08061 

856-423-0258 

800-255-ACHE (2243) 

www.achenet.org 

American Pain Foundation 

201 North Charles Street 

Suite 710 

Baltimore, MD 21201 

888-615-PAIN (7246) 

www.painfoundation.org 

Migraine Research Foundation 

434 1⁄2 East 75th Street 

New York, NY 10021 

212-249-5402 

www.migraineresearchfoundation.org 

National Headache Foundation 

820 North Orleans 

Suite 217 

Chicago, IL 60610 

312-274-2650 

888-NHF-5552 (643-5552) 

www.headaches.org 

45 
46 

Glossary 

abdominal migraine—a type of migraine that 

mostly affects young children and involves 

moderate to severe abdominal pain, with little 

or no headache. 

arteriovenous malformation—a tangle of veins 

and arteries that can disrupt the normal flow 

of blood and is frequently associated with 

episodic headache. 

aura—a warning of a migraine headache. 

Usually visual, it may appear as flashing lights, 

zigzag lines, or a temporary loss of vision, along 

with numbness or trouble speaking. 

autonomic—occurring involuntary. Autonomic 

nervous system dysfunction is frequently 

associated with various types of migraine. 

basilar-type migraine—a type of migraine, 

occurring primarily in young women, causing 

symptoms of abnormal brain stem functioning 

such as double vision, loss of peripheral vision, 

numbness, imbalance, or loss of consciousness. 

benign intracranial hypertension—increased 

pressure within the brain that causes severe 

headaches. It can be caused by clotting in the 

major cerebral veins or from certain medications 

(including some antibiotics, human growth 

hormone replacement, and vitamin A and 

related compounds). 

biofeedback—a process that increases an 

individual’s voluntary control of physiologic 

states such as blood pressure and pain response. 

cephalgia—head pain. 
 

cervical arterial dissection—a tear in an 

artery wall that can lead to stroke or transient 

ischemic attacks. 

cervicogenic headache—a type of headache 

caused by structural irregularities in either the 

neck or head. 

chronic headache—headache that occurs 15 

or more days a month over a 3-month period. 

cluster headache—sudden, extremely painful 

headaches that occur in a closely grouped pattern 

several times a day and at the same times over a 

period of weeks. 

cortical spreading depression—a wave of increased 

brain activity that slowly spreads from the back 

toward the front of the brain’s surface and may 

be the basis for migraine aura. 

episodic—comes and goes. 

ergot derivative drugs—drugs that bind to the 

neurotransmitter serotonin and help to decrease the 

transmission of pain messages along nerve fibers. 

hematoma—a mass or swelling containing blood. 

hemicrania continua—one-sided headaches 

that are chronic or continuous and respond 

to indomethacin treatment. 

hemiplegic migraine—a type of migraine causing 

temporary paralysis on one side of the body. 

hypnic headache—a rare form of headache 

that awakens individuals at night (also called 

“alarm-clock headache”). 

ice cream headache—a painful headache 

brought on by changes in blood flow that result 

from a sudden chilling of the roof of the mouth. 

47 
48 

ischemic stroke—stroke caused by a clot that 

blocks blood flow to the brain. 

medication overuse headache—caused by 

the overuse of drugs (more than 3 times weekly) 

to treat headache; over time, the underlying 

headache becomes worse and occurs more 

frequently, creating a vicious cycle of 

medication use and head pain. 

meninges—the three layers of membrane that 

cover the brain and spinal cord. 

menstrually related migraine—a migraine that 

affects women around the time of their period. 

migraine—headaches that are usually pulsing 

or throbbing and occur on one or both sides 

of the head. They are moderate to severe in 

intensity, associated with nausea, vomiting, 

sensitivity to light and noise, and worsen with 

routine physical activity. 

new daily persistent headache—a type of 

treatment-resistant chronic headache marked 

by daily pain that can last for years. 

neurotransmitters—chemicals in the brain that 

helps nerve cells communicate with each other. 

nociceptors—nerve fiber endings that receive 

and transmit pain signals. 

ophthalmoplegic migraine—an uncommon 

form of migraine featuring a droopy eyelid, 

large pupil, and double vision that may last 

for weeks after the headache pain is gone. 

paroxysmal hemicrania—a rare form of 

headache that usually begins in adulthood and 

is marked by one-sided attacks that typically 

occur 5 to 40 times a day. 
postdrome—the period following the headache. 

premonitory—meaning before. Some individuals 

with migraine experience premonitory symptoms 

up to 24 hours prior to headache pain. 

primary exertional headache—headache brought 

on by fits of coughing or sneezing, or by intense 

physical activity such as running or lifting. 

primary headaches—headaches that occur on 

their own with no detectable underlying cause, 

such as migraine, tension-type headache, and 

the trigeminal autonomic cephalgias. 

primary stabbing headache—also called “ice 

pick headache” or “jabs and jolts” headache 

for its extremely intense pain that develops 

suddenly and generally lasts 1 to 10 seconds. 

retinal migraine—a type of migraine that is 

characterized by attacks of visual loss or 

disturbances in one eye. 

reversible vasoconstriction syndrome—a narrowing of the arteries in the brain that can cause 

sudden, “thunderclap” headache that may be 

brought on by bleeding in or around the brain. 

secondary headaches—headaches that are 

caused by an underlying condition or disease. 

serotonin—a neurotransmitter present throughout the body and brain that plays an important 

role in headache and migraine, mood disorders, 

regulating body temperature, sleep, vomiting, 

sexuality, and appetite. 

status migrainosus—migraine lasting more than 

72 hours. 

49 
50 

SUNCT (Short-lasting, Unilateral, Neuralgiform 

headache attacks with Conjunctival injection and 

Tearing)—a rare form of headache marked by 

brief recurrent bursts of moderate to severe 

burning, stabbing, or throbbing pain, usually 

on one side of the head and around the eye or 

temple, accompanied by symptoms including 

watery, reddish eyes and runny nose. 

tension-type headache—a primary headache that 

is band-like or squeezing and does not worsen with 

routine activity. It may be brought on by stress. 

transient ischemic attack—a stroke that last 

only a few minutes but signals a subsequent and 

more severe stroke. 

trigger—something that brings about a disease 

or condition. 

triptans—a family of drugs used to treat migraines 

and cluster headaches by preventing or stopping 

nerve tissue inflammation and resulting changes 

in blood vessels. 

vascular—refers to blood vessels or the flow of blood. 

venous sinus thrombosis—a form of stroke caused 

by a clot that blocks blood flow in the brain’s veins. 

Credits

Illustrations and photos: 

Page 7, National Cancer Institute 

Pages 24, 34, 42, National Headache Foundation 

Page 32, Jeffrey Aarons 

Page 36, Dr. Rami Burstein 

Written by the Office of Communications and Public Liaison, NINDS 

Why does bright light or noise hurt 

when you have a headache? Why is sleep 

important? How does stress cause headache? 

Basic research tries to answer questions like 

these as we learn how messages are sent and 

influence different parts of the brain. Findings

from such studies can lead to improved 

patient care and headache prevention.

 

 

 

Prepared by: 

Office of Communications and Public Liaison 

National Institute of Neurological Disorders and Stroke 

National Institutes of Health 

Department of Health and Human Services 

Bethesda, MD 20892-2540 

NIH Publication No. 09-158 

August 2009