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Headaches & Migraine

A detailed and accurate description of the headache history is often the most important contributor to accurately diagnosing headaches. It is important to know when the headaches first started, how often they happen, how severe they are, if they respond to medications, and how often pain medications are taken. Furthermore, the precise location of the pain, the description of the pain type, and any factors that worsen the pain are helpful to know. At times, there can be other symptoms associated with the headache, such as an “aura” (sensation) that the headache is coming, sensitivity to light, sensitivity to sound, nausea, changes in vision, tear production, eye redness, or nasal drainage. The presence of these features can lead to an accurate diagnosis. It is important to see if there are any triggers for the headaches, such as certain foods, changes in weather, association with the menstrual cycle, stress, bright lights, stress, coughing, exercise, or others.


Headache – which involves a pain primarily centered in the head – is profoundly common. While Primary Care and Emergency Medicine providers often see people who suffer from headaches, the Neurologist is truly the best expert in this matter. The majority of headaches are primary headaches – suggesting that they have no underlying worrisome cause. However, it is often the fear of an undiagnosed worrisome cause – a secondary headache – that distresses patients. In this way, the Neurologist can offer expertise in both treating the headache and addressing this worry.

Types of Headaches

Primary Headaches

Primary headaches are those in which there is no distinct underlying cause or structural abnormality in the brain. While these can be painful and disabling if not adequately treated, these are not associated with underlying life-threatening diseases.

Secondary Headaches

Secondary headaches are when the headache is a symptom of an underlying disease. The Neurologist will direct an appropriate workup to find and address the process causing the headache. This is less common than primary headaches, but there is great importance in discovering the underlying cause promptly.



Migraines usually start in adolescence and are more common in women than men. Migraine headaches last hours to days. They are often located around an eye and may be associated with nausea, light sensitivity, and sound sensitivity. An “aura” may come before the headache, an abnormal symptom such as visual changes, changes in sensation, or language difficulties that generally last less than an hour. More rare auras may include vertigo, double vision, or weakness; testing must be pursued to rule out other causes. Migraine with aura accounts for about 20% of migraines, while about 80% are without aura.


If migraines occur often and cause disability, starting a medication to prevent or “prophylaxis” against migraine headaches is recommended. This would be recommended if a person has six more or more headaches a month, but other factors can be considered. Options include medications in the classes of beta-blockers (such as propranolol), calcium channel blockers (such as verapamil), anti-epileptics (such as topiramate), or antidepressants (such as amitriptyline). There is a new class of medications called CRGP blockers, which attack a pro-inflammatory molecule associated with migraine. There are many medication options, and the Neurologist will consider the whole person when partnering on this recommendation. There are also non-medication options for migraine prevention, such as Botox injections.


Migraine “abortive” medications should be considered to stop the migraine. These are most effective when taken as soon as possible after a person knows that a migraine headache is starting. The class of medications called “triptans” (such as sumatriptan) is typically used first. These are available as pills, dissolvable tablets, nasal sprays, or injections.


A new CRGP blocker is used to abort headaches (Ubrelvy), which is a good option for those who do not have relief from triptans or have a history of stroke or heart attack. If a headache is severe or lasts long, the Neurologist may recommend a headache infusion, including steroids, Toradol, magnesium, Depakote, and fluids. If the migraine does not go away despite all treatment – called “status migrainosus” – an infusion of DHE can be considered.

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Tension-Type Headache

Tension headaches are the most common type of headache. They are characterized by a dull, aching pain that feels like a tight band around the head. The pain can be mild to moderate and is often worse on both sides of the head. Tension headaches can last for hours or days and may be accompanied by other symptoms such as neck pain, stiffness, and fatigue.

The exact cause of tension headaches is unknown, but they are thought to be caused by muscle tension in the head and neck. Stress, anxiety, and poor posture are all factors that can contribute to tension headaches.


Several things can be done to prevent or relieve tension headaches. These include:

  • Relaxation techniques: such as yoga, meditation, or massage.

  • Getting enough sleep: 7-8 hours per night.

  • Managing stress: through exercise, relaxation techniques, or therapy.

  • Maintaining good posture: when sitting, standing, or lying down.

  • Avoid caffeine: and alcohol, as these can dehydrate the body and worsen headaches.

  • Taking over-the-counter pain relievers: such as ibuprofen or acetaminophen.


Cluster Headache

Cluster headaches are characterized by recurring episodes that span from several weeks to several months, during which these intense headaches manifest at a minimum daily frequency, typically lasting anywhere from 30 minutes to 2 hours. These headaches exhibit a notable gender predisposition, with a higher prevalence in men compared to women. They often exhibit particular triggers, such as alcohol consumption, and may exhibit a proclivity for nocturnal onset.

The distinct pain associated with cluster headaches is localized to one side, often concentrated around the eye or in close proximity to the temple. The nature of this pain is frequently described as searing or sharp, and its onset is marked by rapidity. Notably, these headaches are often accompanied by additional symptoms, such as drooping of the eyelid, excessive tearing, a reddened eye, or a runny nose. The severity of this pain can be profoundly incapacitating.

For managing cluster headaches in the acute phase, abortive treatments are employed. These include the utilization of oxygen therapy or the administration of sumatriptan injections. In terms of prevention, the use of a calcium channel blocker named verapamil has demonstrated efficacy.

Within the realm of "trigeminal autonomic cephalgias," a cluster of headache types that share certain characteristics, similar patterns emerge. These conditions all revolve around the activation of the trigeminal nerve. Diagnosis can be influenced by the duration and frequency of the headache episodes, with some variations in symptomatology. In some cases, differentiating between these headache types can be aided by a trial of the NSAID Indomethacin.

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Brain Tumor

Headache associated with a brain tumor is a notable clinical manifestation that warrants attention. The development of a brain tumor can lead to increased intracranial pressure, which can trigger headaches. The nature of these headaches can vary widely, but they often exhibit certain distinctive features. These headaches are typically persistent, progressively worsening over time. They may also be more intense upon waking up or during straining activities, such as coughing or bending over.

Furthermore, these headaches are often refractory to typical headache medications. Unlike primary headaches, they might not respond well to rest or relaxation. The pain might be localized to a specific area, and its character could be described as throbbing, dull, or constant. Additionally, accompanying neurological symptoms might be present, such as changes in vision, coordination difficulties, or cognitive impairments.

It's important to note that while headaches can indicate a brain tumor, they are not definitive diagnostic markers. Many other benign conditions can also cause headaches. Therefore, a medical professional should thoroughly evaluate any persistent, severe, or unusual headaches. Diagnostic imaging, such as MRI or CT scans, might be necessary to determine the presence of a brain tumor or other underlying causes. Early detection and intervention are crucial for appropriate management and treatment.

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Low CSF Pressure

Headaches stemming from low cerebrospinal fluid (CSF) pressure represent a distinct clinical phenomenon with noteworthy implications. This condition, known as intracranial hypotension, arises when the normal fluid pressure surrounding the brain and spinal cord decreases. As a consequence, a characteristic type of headache emerges. These headaches are often described as severe, throbbing, and positioned at the back of the head. They can intensify upon standing or sitting upright and might be alleviated when lying down.

The underlying mechanism involves the reduction of CSF cushioning that normally separates the brain from the skull. When this cushioning diminishes, the brain can experience greater contact with the skull, leading to discomfort. This condition is often associated with cerebrospinal fluid leaks, which can be caused by medical procedures, spinal taps, or underlying connective tissue disorders.

Diagnosis often involves medical history, physical examination, and imaging tests like magnetic resonance imaging (MRI) or computed tomography (CT) scans to visualize any potential fluid leaks. Treatment strategies aim to address the underlying cause and alleviate symptoms. In some cases, conservative measures such as bed rest, hydration, and caffeine intake might be recommended. If a cerebrospinal fluid leak is identified, interventions like epidural blood patches or surgical repairs might be considered to restore proper fluid pressure and alleviate associated headaches.

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Headache with Abrupt Onset

The term "thunderclap headaches" derives from their abrupt and intense onset, rapidly escalating to peak severity within seconds. These headaches raise considerable concern due to their distinctive characteristics. Of paramount worry is the potential link to a subarachnoid hemorrhage, marked by bleeding near the brain's protective coverings. This type of headache often arises from the rupture of a cerebral aneurysm, a weakening in the blood vessel wall within the head that bursts and releases blood. Such an event can lead to mortality rates of up to 50%, underlining the urgency of recognizing and addressing it.

Medical professionals employ techniques like head CT scans and, on occasion, lumbar punctures to swiftly assess the possibility of a subarachnoid hemorrhage. These diagnostic measures aid in determining the presence and extent of bleeding. Notably, recurrent occurrences of thunderclap headaches are infrequent but merit careful consideration. In some cases, they might be attributed to a condition called Reversible Cerebral Vasoconstriction Syndrome (RCVS), which involves the temporary constriction of cerebral blood vessels.

Given the potentially dire implications, prompt evaluation and management of thunderclap headaches are imperative. Timely identification of a subarachnoid hemorrhage allows immediate intervention, reducing the associated mortality risk. Moreover, understanding potential underlying conditions, such as RCVS, aids in providing appropriate treatment strategies and improving patient outcomes. As such, any sudden and excruciating headache demands immediate medical attention to ensure accurate diagnosis and proper intervention.

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Temporal Arteritis

Trigeminal neuralgia (TN) is the most prevalent form of recurrent facial pain, with its incidence rising notably after age 40. This condition typically manifests in episodes characterized by fleeting yet intensely excruciating sensations akin to electric shocks or shooting pain, primarily afflicting one side of the face, often concentrating in the mid to lower facial regions. These brief episodes, lasting only seconds, can be triggered by stimuli like cold air, wind, or even the slightest contact with the teeth.

While TN can manifest idiopathically without an identifiable cause, it can also arise due to underlying conditions such as multiple sclerosis, tumors, or the trigeminal nerve compression by blood vessels. Accurate diagnosis entails a comprehensive assessment, including brain MRI and vascular imaging, to ascertain potential contributing factors.

The therapeutic approach to TN involves carbamazepine as the preferred choice, though alternative medications are also viable. In instances where pharmaceutical interventions prove ineffective, more invasive measures are considered. Procedures like microvascular decompression, aimed at alleviating nerve compression, or gamma-knife radiofrequency ablation, targeting nerve dysfunction with focused radiation, can be explored as treatment avenues.

The multifaceted nature of trigeminal neuralgia necessitates a thorough diagnostic journey and tailored management strategies. By encompassing pharmacological and procedural interventions, healthcare professionals aim to mitigate the profound impact of this debilitating condition on patients' quality of life.


Idiopathic Intracranial Hypertension

Idiopathic Intracranial Hypertension (IH), also commonly known as Pseudotumor Cerebrii, arises from elevated cerebrospinal fluid (CSF) pressure within the brain, indicating excessive pressure exerted by the brain's fluid. While distinct from brain tumors, the characteristics of the headaches associated with IH often bear a resemblance to those related to brain tumors. These headaches are frequently accompanied by visual disturbances and a pulsatile ringing sensation in the ears. IH is predominantly prevalent among young women, with a higher risk observed in individuals who are overweight.

The diagnostic process for IH involves critical steps to differentiate it from other conditions. This includes a lumbar puncture to measure the opening pressure of CSF and an MRI of the brain to exclude the presence of any masses. Additionally, imaging of the cranial veins might be conducted to rule out any potential obstructions.

Effective management of IH involves a multifaceted approach. Carbonic anhydrase inhibitors, a class of medications including topiramate, are often employed to diminish CSF production, thereby reducing intracranial pressure. In cases where symptoms are not adequately controlled by medications or vision deteriorates, more invasive interventions might be contemplated. These could encompass procedures like ventriculoperitoneal (VP) shunt placement to divert excessive CSF or optic nerve sheath fenestration to relieve pressure around the optic nerve.

The intricacies of diagnosing and managing IH underline the significance of accurate assessment and personalized therapeutic strategies. By addressing both the elevated CSF pressure and the associated symptoms, medical professionals aim to improve patients' well-being and mitigate the potential impact on vision and quality of life.

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Medication Overuse Headache

Regrettably, the paradoxical outcome of increased headache occurrences due to the excessive use of seemingly innocuous over-the-counter or prescribed pain medications can be perplexing. This phenomenon underscores the significance of conveying accurate medication usage patterns to the attending Neurologist. Understanding the frequency and quantity of pain medication consumption aimed at managing headaches is pivotal in recognizing and addressing medication overuse headaches.

In essence, the very medications intended to alleviate headaches can inadvertently contribute to a cycle of rebound headaches. This presents a challenging scenario wherein overusing pain medications can lead to more frequent and severe headaches. Neurologists play a crucial role in assessing this complex dynamic by evaluating the medication regimen and its correlation with headache patterns.

Addressing this issue requires a comprehensive strategy. If overuse of pain medications is identified as a contributing factor, a tailored plan to gradually reduce medication consumption is imperative. Collaboratively designed between the patient and the Neurologist, this plan aims to break the cycle of rebound headaches and pave the way for improvement. An effective approach involves not only reducing medication but also exploring alternative pain management strategies to prevent dependency on medications.

By transparently communicating medication usage and working closely with the Neurologist, individuals can navigate the challenges of medication overuse headaches. This partnership allows for the development of a personalized plan that promotes long-term headache management, ultimately leading to enhanced well-being and a higher quality of life.

Headaches can arise from a multitude of factors. Common tension headaches result from muscle tightness in the head, neck, or shoulders. Sinus headaches occur due to inflammation in the sinus passages, often linked to allergies or infections. Dehydration can trigger headaches, emphasizing the importance of adequate fluid intake. Eyestrain-related headaches emerge from extended screen time or incorrect eyeglass prescriptions.

Migraines, with genetic predispositions, involve complex neurochemical changes leading to pulsating pain, light sensitivity, and nausea. Cluster headaches, affecting one side of the head, correlate with neurological activity and are intensely painful. Infections such as colds, flu, or sinusitis can induce headache symptoms, while post-traumatic headaches follow head injuries or concussions.

Certain medical conditions like high blood pressure or medication side effects can contribute to headache occurrences. However, it's crucial to recognize that severe headaches might indicate underlying issues like brain tumors, aneurysms, or inflammation. Prompt medical evaluation is essential to diagnose and manage such cases accurately, ensuring the best possible outcomes.

Causes of Headache

Signs and Symptoms of Different Headaches

Different types of headaches present with distinct sets of symptoms. Tension headaches often cause a dull, steady ache on both sides of the head, accompanied by muscle tension in the neck and shoulders. Conversely, migraines involve throbbing pain, often unilateral, intensified by physical activity, and accompanied by nausea, vomiting, and sensitivity to light and sound.

Cluster headaches typically produce excruciating, sharp pain on one side of the head, usually around the eye or temple. These can be accompanied by redness of the eye, tearing, a runny nose, and drooping of the eyelid on the affected side. Sinus headaches are characterized by pressure and pain in the cheeks, forehead, or nose bridge, exacerbated by bending forward.

In the case of cervicogenic headaches, discomfort originates in the neck and radiates to the head. Secondary headaches, resulting from underlying conditions like infections or brain disorders, exhibit various symptoms depending on the specific cause. Recognizing these distinct symptoms aids in accurate diagnosis and appropriate management strategies tailored to each headache type.

Diagnosing different types of headaches involves a combination of clinical evaluation, patient history, and sometimes diagnostic tests.


For tension headaches, doctors rely on the patient's description of the headache's characteristics and triggers. Migraines are often diagnosed based on the presence of specific symptoms like nausea, sensitivity to light, and throbbing pain, with additional tests to rule out other causes. Cluster headaches are typically diagnosed by their distinct pattern of severe, one-sided pain around the eye, accompanied by symptoms like tearing and nasal congestion.


Sinus headaches may require imaging studies like CT scans to assess sinus inflammation. Cervicogenic headaches are diagnosed by identifying neck pain as the source of head discomfort. Secondary headaches necessitate identifying the underlying condition through thorough medical evaluation and diagnostic tests, such as MRI or blood tests. Accurate diagnosis ensures tailored treatment plans, addressing the root cause and alleviating symptoms effectively.

Diagnosis of Headaches


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Treatment of Headaches

The treatment of different types of headaches varies based on their underlying causes and specific symptoms. For tension headaches, stress management, relaxation techniques, and over-the-counter pain relievers are often effective. Migraine treatment involves both acute and preventive measures. Acute management includes rest, avoiding triggers, and medications like triptans or NSAIDs. Preventive strategies encompass lifestyle changes, medications, and identifying and managing triggers.

Cluster headaches may require prescription medications like triptans, oxygen therapy, or nerve blocks to alleviate acute pain. Sinus headache treatment focuses on managing the underlying sinus infection with antibiotics, decongestants, and pain relievers. Cervicogenic headache therapy involves physical therapy, chiropractic care, and exercises to improve neck posture and alleviate pain.

Secondary headaches demand treating the underlying condition. For instance, addressing high blood pressure or managing infections can lead to headache relief. Individualized treatment is crucial, as different patients respond differently. A comprehensive approach considers the headache type, its frequency, and the patient's medical history. Collaborating with healthcare professionals ensures accurate diagnosis and tailoring effective treatment strategies, ultimately improving the patient's quality of life.

The prognosis of different types of headaches varies based on their causes, management, and individual factors. Tension headaches generally have a favorable prognosis, as they often respond well to lifestyle modifications, stress management, and over-the-counter pain medications. Proper management allows these headaches to be effectively controlled, allowing individuals to resume normal activities.

Migraine prognosis varies, with some experiencing occasional episodes that respond to medications while others might have more frequent or severe attacks. Lifestyle adjustments and preventive measures can significantly improve the prognosis, minimizing the frequency and severity of migraines.

Cluster headaches tend to recur in cycles, lasting weeks to months. Although pain intensity can be highly debilitating, treatments like oxygen therapy or specific medications can help manage the condition, providing relief during active periods.

Sinus headaches caused by infections usually resolve with proper treatment of the underlying disease, leading to a favorable prognosis. Cervicogenic headaches may improve with physical therapy and postural adjustments.

Secondary headaches' prognosis hinges on effectively managing the underlying cause. The associated headaches often improve if the root condition is addressed and treated.

In all cases, early diagnosis, appropriate treatment, and effective communication with healthcare professionals enhance the prognosis. Customized management plans that consider the individual's health, triggers, and lifestyle can improve headache control and overall quality of life.


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