Headaches are common. Almost everyone will have headaches at some point in their lives. Most headaches can be diagnosed after a clinical history and examination. Headaches are classified as to whether there is no underlying cause – primary headaches, or where there is a known condition causing the headaches. Mostly headaches do not have a sinister underlying cause.

Tension headache and migraine are the two most common primary headaches. There are a number of other rare but well defined syndromes that benefit form medical therapy.

People experiencing headaches will typically self medicate with over the counter pain killers. Medical attention is sought when there is concern about serious underlying cause, or headaches are particularly troublesome or disabling. Most of these are dealt with in general practice but referral to a specialist is made when there is a sudden severe first headache, headaches are progressive or treatments fail to be of benefit or where there are other worrying features.

The following are examples of primary headaches:
• migraine
• tension headache
• cluster headache
• primary cough headache
 

Migraine is common, affecting about 15% of the population. It is an episodic headache. It is usually one sided with a pulsating quality and lasts between 4 to 72 hours. Key features include nausea, vomiting, and an intolerance of bright light, sound and smells. A warning or aura is often but not always present. This is classically a visual disturbance (zig-zag lines) that lasts up to thirty minutes immediately before the onset of headache.

Migraineurs will want to rest or sleep in a quiet darkened room until an attack has passed. Sufferers are usually unable to function normally during an attack, and for those with frequent or prolonged episodes it is a particularly disabling condition.    

Migraine treatment can be considered at three levels:
• Lifestyle measures, this includes identification and avoidance of triggers, for example certain foods, hunger, irregular sleep pattern
• Treatment for acute attacks – simple pain killers, anti-sickness medication and specific antimigraine drugs (triptans)
• Preventative treatment – daily medication to prevent attacks. This is considered in those with frequent attacks, say 2 or more per month.  
 

Unlike migraine, tension headache tends not to have associated features such as nausea or visual symptoms. Sufferers are often able to continue their daily activities despite the headache. Tension headaches are caused by muscle contraction in the scalp and neck, they are not as the name might suggest necessarily related to stress.

Tension headaches are often described as a tight band or feeling as though wearing a hat, often with sharp exacerbations. They are typically constant and daily and can last for months or sometimes years. Treatment again involves identification of triggers, regular exercise, and sometimes medication treatment with amitriptyline. Regular daily pain killers should be avoided, particularly those containing codeine as these can lead to an analgesic overuse headache. 
 

There are a number of other primary headache syndromes, these are relatively rare. Effective treatment is reliant on accurate diagnosis. Cluster headache is an episodic headache syndrome, with severe one sided headaches. However unlike migraine the episodes of pain are shorter, more frequent, occur in clusters and rather than wanting to lie still the sufferer is restless and will often pace around or clutch their head.

A number of conditions can cause headaches. These are known as secondary headaches. Some of these are serious or life threatening and require immediate medical attention.

The following are examples of secondary headaches:
• meningitis
• subarachnoid haemorrhage
• brain tumours
• giant cell arteritis (temporal arteritis)
• analgesic overuse headache
• viral illness
 

The assessment of the patient experiencing headache rests heavily on an investigation of the clinical history of headaches, including:

• onset
• location
• quality
• duration
• variation over time
• exacerbating and relieving factors
• triggers
• associated features, eg visual symptoms, nausea

In addition to this, a previous medical history, concomitant medication, family and social history can give clues as to the cause of headaches.

A physical examination looks for signs of secondary headache. This includes musculoskeletal causes for example scalp or neck tenderness, and blood pressure. Neurological examination looks for signs of raised intracranial pressure and focal neurological deficits.
 

Tests are carried out where the diagnosis is not clear or to support a suspected clinical diagnosis. Tests are not always necessary, for example when there is an obvious clinical diagnosis of a benign headache syndrome, for example migraine or tension headache. The following are examples of some of the tests used in investigating headache:

• Blood tests – for example to look for sign of infection or inflammation
• Brain scan with CT (computed tomography) or MRI (magnetic resonance tomography)
• Chest X-ray
• Lumbar puncture