# Headache

## What is a headache?

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.

Headaches can range in frequency and severity of pain. Some individuals may experience headaches once or twice a year, while others may experience them 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.

**Why headaches hurt**

The trigeminal nerve has three branches that conduct sensations from the scalp, the blood vessels inside and outside of the skull, the lining around the brain (the meninges), and the face, mouth, neck, ears, 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 following explains what each of these body parts does on a regular basis: 
              - The trigeminal nerve—one of 12 pairs of cranial nerves that start at the base of the brain—sends information about touch, pain, temperature, and vibration in the head and neck is sent to the brain. 
              - 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 also may be part of the process, causing nausea, vomiting, diarrhea, trouble concentrating, and other neurological symptoms.

## Who is more likely to get a headache?

Anyone can experience a headache. Certain types of headache run in families. Migraines occur in both children and adults but affect adult women three times more often than men.

**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. Unlike 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
              - Certain foods and drinks

Of special concern 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.

Migraine is often misdiagnosed in children. 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 75 percent 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 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, too little or too much sleep 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 headache are treated using antidepressants. Check with a doctor before using over-the-counter medicines to ease sleep-associated headaches.

## How is a headache diagnosed and treated?

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 and/or 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

**Diagnosing 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
                    - 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 disorders. A pattern may emerge that can be helpful to reducing or preventing headaches.

Once your doctor reviews your medical and headache history and conducts physical and neurological exams, lab screening and diagnostic tests may be ordered to either rule out or identify conditions that might be the cause of your headaches. 

Blood and urine tests can help diagnose brain or spinal cord infections, blood vessel damage, and toxins that affect the nervous system. Testing 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, 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.

**Headaches and their types of treatment**

Primary headaches occur independently and are not caused by another medical condition. 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. 

Primary headache disorders are divided into four main groups: 
              - Migraine 
              - Tension-type headache
              - Trigeminal autonomic cephalgias (including cluster headache)
              - Miscellaneous primary headache

**Migraine**Migraine headaches are characterized by recurrent attacks of moderate to severe throbbing and pulsating pain on one side of the head. The pain is caused by the activation of nerve fibers that reside within the wall of brain blood vessels traveling within the meninges. 

Untreated attacks last from four to 72 hours. Other common symptoms are:
              - Increased sensitivity to light, noise, and odors
              - Nausea 
              - 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 environment 
                    - 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
                    - Bright or flashing lights

Medication overuse or missed doses also may cause headaches. Foods or ingredients like the ones listed below can trigger headaches; keeping a diet journal can help you identify your triggers.

                    - Aspartame
                    - Caffeine (or caffeine withdrawal)
                    - Wine and other types of alcohol
                    - Chocolate
                    - Aged cheeses

                    - Monosodium glutamate (MSG)
                    - Some fruits and nuts
                    - Fermented or pickled goods
                    - Yeast
                    - Cured or processed meats

**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, darkened room
              - Placing a cool cloth or ice pack on the forehead
              - 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 the drugs enenmab (Aimovig) for the preventive treatment of headache and galcanezumab-gnlm (Emgality) injections to treat episodic cluster headache. The FDA also has approved lasmiditan (Reyvow) and ubrogepant (Ubrelvy) tablets for short-term treatment of migraine with our without aura. 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 are the preferred treatment for migraine because they can alleviate moderate to severe migraine pain.
              - Ergot derivative drugs bind to serotonin receptors on nerve cells and decrease the transmission of pain messages along nerve fibers. They are most effective during the early stages of migraine.
              - Non-prescription analgesics or over-the-counter 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, 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 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 also are recommended for individuals who take symptomatic headache treatment more than three times a week. Physicians also will recommend that a migraine sufferer take one or more preventive medications two to three 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 originally developed for treating epilepsy, these drugs increase levels of certain neurotransmitters and dampen pain impulses.
              - Beta-blockers are used to treat high blood pressure and are often effective for migraine.
              - Calcium channel blockers are used to treat high blood pressure treatment 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 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 also may affect levels of other chemicals, such as norepinephrine and dopamine. 

Natural treatments for migraine include riboflavin (vitamin B2), magnesium, coenzyme Q10, and butterbur (plant extract).

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.

For additional information on migraine, see the NINDS migraine information page.

**Tension-type**Tension-type 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 also may be caused by: 
              - Jaw clenching
              - Intense work
              - Missed meals
              - Depression
              - Anxiety
              - Not enough sleep

Sleep apnea also may 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 also may 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 three-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 also may be helpful.

**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, 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 pain-free 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 five to 10 minutes after onset and continues at that intensity for up to three 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. These headaches often wake people from sleep.

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 one to three cluster headaches a day with two 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 (one 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 non-invasive vagus nerve stimulation (which uses a hand-held device to provide electrical stimulation to the vagus nerve through the skin), galcanezumab-gnlm injections, triptan drugs, and oxygen therapy (in which pure oxygen is inhaled through a mask to reduce blood flow to the brain). Certain antipsychotic drugs, calcium-channel 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.

**Paroxysmal hemicrania**

Paroxysmal hermicrania 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 five to 40 times per day, with each attack lasting two 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—individuals experience attacks on a daily basis for a year or more.
              - Episodic—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. 

For additional information, see the NINDS paroxysmal hemicrania information page.

**SUNCT**

SUNCT, which stands for 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 five seconds to four minutes per episode. Individuals generally have five to six attacks 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 1year.

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
                    - 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.

For additional information see the NINDS SUNCT information page.

**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 three-month period. In addition to chronic tension-type headache, chronic migraine, and medication overuse headache (discussed above), 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 six months and are followed by a pain-free period of weeks to months before recurring. Most individuals have attacks of increased pain three to five 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. For additional information on hemicrania continua, see the NINDS information page (insert link to hemicrania continua page)
              - **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
                - 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 one 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 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 two 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 pain.

**Hypnic headache**, previously known as "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 three hours after waking and are most often felt on both sides of the head. Other symptoms include nausea or increased 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.

**Ice cream headache**(sometimes called "brain freeze”) 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 five 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**

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 result from underlying conditions that affect the brain. 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. Treatment options include surgery, radiation therapy, and chemotherapy. However, most individuals with headache do not have brain tumors.

**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 stroke: 
              - Hemorrhagic, which occurs when an artery in the brain bursts, spilling blood into the surrounding tissue
              - Ischemic, which 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** 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 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 blood-thinning 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 thunderclap-like 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.
                - 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.
              - 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.
                - 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 drinking alcohol, following carbon monoxide poisoning, or from exposure to toxic chemicals and metals, cleaning products or solvents, and pesticides. 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 also can cause headaches.

**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 vessels, which result in an accumulation of blood called a hematoma. This mass of 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 seen in young, overweight females. 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 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
              - Anticonvulsants

Headaches also may 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. 

**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
              - 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 own blood into the low 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 worsen 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.

**Self-care or lifestyle changes**

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 with headache cope with their pain and discomfort. Relax whenever possible to ease stress and related 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 are the latest updates on headache?

The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health (NIH), supports research on headaches that may lead to new treatments or perhaps ways to block debilitating headache pain. Studies by other investigators are adding insight to headache etiology (investigation of the cause) and treatment.

**Understanding headache**

NIH supports research on the mechanisms and causes of migraine pain including the roles of genetics, gender, and hormones in migraine, and how pain fibers in different parts of the brain and in the brain lining contribute to migraine. NINDS-funded researchers are investigating the influence of other conditions, particularly obesity and sleep disturbance, on migraine onset and severity and the connection between migraine and depression

NINDS funds several projects to develop animal models of headache pain and migraine, which help us to better understand headache mechanisms and test promising therapies. Scientists are using state-of-the-art imaging to detect disease processes and brain changes that occur in headache disorders as well as how headaches result from concussions.

**Developing and testing new therapies**

Scientists funded by NINDS are identifying and testing new drug and other treatment options, such as developing drug candidates for migraine prevention that block the action of the kappa opioid receptor, which has been linked to stress—a potent migraine trigger. Other NINDS-sponsored researchers are studying chemical communication between various types of cells, such as immune cells and pain-sensing cells, which may give rise to novel targets for acute and preventive headache treatment. NIH-funded research into non-drug approaches to relieve migraine headache include the use of different colored room lighting and if dietary omega-3 polyunsaturated fatty acids might improve clinical outcomes.  

The NINDS-supported Childhood and Adolescent Migraine Prevention Study (CHAMP) compared two commonly prescribed medications (amitriptyline and topiramate) to prevent recurrent migraines in children and adolescents. The findings suggest that migraine treatments for adults may not necessarily work in young people.

In 2019, NINDS developed Migraine Trainer, an Android app to help users ages 13+ understand possible causes of their migraines and take a greater role in their treatment by creating an individual migraine management plan with their parents and medical team. 

**Coordinating Pain Research**

Several NINDS activities on pain research—including headache—are focused on coordinating efforts across NIH and with other federal agencies:
              - The NIH Pain Consortium, a collaboration of 25 NIH institutes and centers, helps identify, coordinate, promote funding opportunities, and support pain research initiatives and activities at NIH. 
              - The Interagency Pain Research Coordinating Committee (IPRCC) is a Federal advisory committee created by the Department of Health and Human Services (HHS) to better understand and treat pain.  
              - The National Pain Strategy, “a comprehensive population health-level strategy for pain,” is being implemented and coordinated by the HHS Office of the Assistant Secretary for Health and the NINDS Office of Pain Policy and Planning. 
              - The Federal Pain Research Strategy, a long-term strategic plan for pain research being developed through the NINDS Office of Pain Policy and Planning and the IPRCC, will prioritize research to relieve pain and improve pain care through evidence-based studies.
              - The NIH HEAL Initiative is an aggressive, trans-NIH effort to speed scientific solutions to stem the national opioid public health crisis. Launched in April 2018, the initiative is focused on improving prevention and treatment strategies for opioid misuse and addiction and enhancing pain management. As part of NIH HEAL, NINDS is focused on understanding pain mechanisms and developing effective, non-addictive treatments for pain. The initiative also supports migraine research.

For research articles and summaries on headache, search PubMed, which contains citations from medical journals and other sites.

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## How can I or my loved one help improve care for people with headaches?

Consider participating in a clinical trial so clinicians and scientists can learn more about headache. Clinical research uses human volunteers to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease. 

All types of volunteers are needed—those who are healthy or may have an illness or disease—of all different ages, sexes, races, and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them. 

For information about participating in clinical research visit NIH Clinical Research Trials and You. Learn about clinical trials currently looking for people with headache at Clinicaltrials.gov, a searchable database of current and past clinical studies and research results.
> Where can I find more information about headaches?
Information is available from the following organizations:

American Headache Society Committee for Headache Education (ACHE)Phone: 856-423-0043

American Chronic Pain Association (ACPA)Phone: 916-632-0922 or 800-533-3231

National Headache FoundationPhone: 312-274-2650 or 888-643-5552

## Learn about related topics

              - Hemicrania Continua
              - Migraine
              - Migraine Trainer
              - Pain 
              - SUNCT Headache

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