Headaches

A headache is not a disease but a symptom of other diseases, usually neurological or alterations of cranial structures (musculature, bones, dental pieces, paranasal sinuses, etc.), they cause an activation of pain receptors that depend on the trigeminal nerve or the first cervical nerve roots.

Although the vast majority of people will present occasional and mild headaches, in some cases, the same headache and the rest of the symptoms of the diseases that cause it can interfere seriously in their usual daily life activities, generating disability and a significant decrease in quality of life. This combination of high prevalence, along with the great diversity of causes, some of them potentially disabling, makes the assessment of patients with headache a clinical challenge.

Symptoms

Headache is defined as presenting pain in any area of the head or face. When evaluating a person who has a headache it is important to specify the characteristics of the pain, these include:

• Location: Hemicranial (half-head), holocranial (whole head), frontal, temporal, occipital, facial, etc.
   
• Character: stabbing, oppressive, pulsating or beating, burning, electrical etc.
   
• Severity: Mild, moderate, intense, very intense.
   
• Duration of the episodes: Seconds, minutes, hours, days, constant.
   
• Form of onset and evolution.
   
• Frequency and timing of episode appearance.
   
• Factors that improve or worsen pain, like certain postures or manoeuvres such as cervical movements, tactile stimuli at certain points, eating, speaking or brushing the teeth.

In addition to the characteristics of pain, it is especially important to know what other symptoms accompany pain, since they give us a lot of information about the possible causes of a headache:

• Fever or cervical stiffness may indicate infections of the nervous system.
   
• Neurological symptoms such as loss of vision, strength or sensitivity or sudden speech disturbances may indicate brain diseases such as stroke or migraine.
   
• Sensitivity to stimuli such as light, noise or smells are common in migraine.
   
• Nausea or vomiting is common in migraine, but may also appear in patients with brain injury or hydrocephalus.
   
• Teary eyes, a runny nose or red eyes during pain are typical of trigemino-autonomous headaches such as cluster headaches.

Who is affected by the condition?

Most people will have a headache at some point in their life, and it is a symptom that can present at any stage from childhood to old age. Migraine and tension headaches are the most common causes of headache and particularly affect women aged between 15 and 55, being the third leading cause of disability in young adults (under 50 years of age).

Children and adolescents may also have headaches. Children have the same types of headaches as adults, but their symptoms can be a bit different, which can make it difficult to identify the type of headache.

Diagnosis

Headaches are divided into 3 groups:

• Primary headaches: They are diseases in which their main symptom is headache, which is recurrent. Examples include migraine, tension headache or trigeminal-autonomous headaches. It is the most frequent cause of headache, and usually there are no alterations in routine tests.
   
• Secondary headaches: Caused by other diseases that cause headache among other symptoms. Examples include headache attributed to cranial trauma, cerebrovascular diseases such as ischemic or haemorrhagic stroke, problems with cerebrospinal fluid pressure or the effects of substances or drugs.
   
• Neuralgia or painful neuropathies: Such as trigeminal neuralgia, which occur due to lesions in the cranial nerves.

For most people who have headaches, especially those who have presented several episodes throughout their lives, the diagnosis will be made through clinical interview and physical exploration and, most of the time, will not require any tests. The way the episodes of headache present is the key to being able to make the correct diagnosis.

When faced with a first episode of headache, especially if it is sudden or accompanied by alarm signs (e.g. fever, cervical stiffness or neurological symptoms) it will be necessary to rule out that it is a serious secondary headache. In these cases it will be especially important to perform blood tests, cerebrospinal fluid and brain imaging tests such as CT scans or magnetic resonance imaging.

Typical treatment

There are two types of treatment: Treatment of pain is usually performed with analgesic or anti-inflammatory drugs that will be adjusted according to the patient's response or tolerance. In addition, in cases of secondary headache it will be important to treat the cause. It is important to know that in the case of frequent headaches, understood as several days a month, the frequent use of painkillers can be harmful and the frequency must be evaluated with calendars in order to initiate preventive treatments, which aim to decrease the frequency and intensity of frequent headaches.

Typical tests

Most of the information required for diagnosis is obtained from clinical interview and physical examination, and thus most patients with headache, especially those who exhibit long-evolution headache episodes, will not need specific supplementary tests for diagnosis. The need for complementary explorations such as blood tests, cerebral or spinal neuroimaging (CT or MRI), lumbar puncture for cerebrospinal fluid tests or vascular tests are indicated in patients who present "alarm signs" that include:

• Sudden onset.
• Progressive worsening.
• Start during gestation or postpartum.
• Onset in people over 50.
• Alteration of the level of consciousness or neurological symptoms.
• Associated with symptoms such as fever, cervical stiffness, weight loss.
• Associated with systemic diseases (cancer, HIV infection, systemic infection, coagulation disorders).
• Triggered by postural changes.
• Triggered by cough or physical activity.
• Papilledema (alteration to the fundus of the eye).

Prevention

Preventive strategies will be especially important in people with recurrent headaches such as migraine or tension headache, in order to minimize the factors that can make the headaches appear more frequently. It is especially important to have regular routines, perform correct sleep hygiene and regular exercise. These measures will also be important to prevent overloading of the cervical or cranial musculature; or strategies to minimize stress and mood disorders.