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How a Harvard Doctor Diagnoses 3 Types of Headaches
How does an experienced doctor diagnose a headache? Dr. Smetana is a renowned professor of medicine at Harvard Medical School. Read his take and knowledge on migraines, tension-type, and cluster headaches.
Posted on April 19, 2017 by Team Medicine after an interview with Dr. Gerald Smetana
New vs old headache
Three types of headaches
Treatment for primary headaches
Neck and sinus headaches
More on Dr. Smetana
What do you think about first when differentiating different types of headache?
Headache is a very common symptom in primary care practice. It's usually in the top 5 of symptoms that prompts someone to come in and see a physician. I usually suggest that the most important first step when seeing someone with a headache is to determine if it’s a new headache or an old headache. Old headaches are usually benign. By old headaches, I mean headaches of long standing duration. To those asking further questions, it will be migraine or tension-type headaches. It's really in the new headache category that we have to pay most attention because the potential for serious cause of headache is much higher in somebody with a new headache. A new headache will either be in someone that doesn't normally have outstanding headaches that's straightforward. Another that’s more challenging for patients and doctors would be a change in the character of an old headache. By that I mean patients with old headache like migraine for example, are immune in developing other causes for headache and over their lifetime. There could potentially be a serious cause and the clue would be a change in the character of the headache.
New vs old headache
Change in frequency or severity, as long as the headache character is the same, is still considered to be an old headache. Once we get that history, we have to figure out why are the migraines worse, but there is still a migraine. A change in the character would mean a completely different description. For example, if a patient comes in to see me and they have long standing migraines that are in one temple and throbbing, paired with nausea, and now when they come in, their headache is across both sides of the forehead, non-throbbing and persistent. That can be much less intense than the usual migraine but is still new because the character is different. Then we would be responsible for understanding and determining why the character is different. This could be a new diagnosis even if the severity is less than their usual headache.
In terms of old headaches, most of those tend to be migraine or tension-type, cervicogenic headache or more rarely, cluster headache which is less common. Some of the other classes of headache would be in the new category. For example, headache of benign causes could be headache due to a flu or sinus disease. The worrisome causes for headache would also be in that group. A new headache category I would be worried about and that a patient would be concerned about as well, would be the possibility for a mass lesion in the brain or a brain tumor. That would prompt patients to come in to see a doctor. They feel that something has changed that could be serious. They could also be due to infection inside the brain and that could be for example, meningitis or abscess in the brain. It can be due to certain vascular or blood vessel abnormalities. One of those would be an AVM or arteriovenous malformation and that’s a tangle of blood vessels in the brain that’s congenital. People have had it since childhood but may have symptoms for the first time as an adult. Sometimes it can be confused for a migraine. For older patients, and I use the cutoff to be about 50, one that we are worried about is called Giant-cell or temporal arteritis, which is an inflammation in the blood vessel leading to the scalp and brain. If it's not properly diagnosed, it would lead to visual loss. Some benign causes of new headaches too could be temporomandibular joint ,TMJ, or jaw pain from grinding teeth. I mentioned the neck related headaches already and with these symptoms, often determined to be cervicogenic headache or sometimes called occipital neuralgia or nerve pain from the back of the skull that can cause pain that goes over the top of the head. It can be a new headache that occurs for the first time in an adult either by arthritis in the spine or sometimes what we see after a whiplash injury or a motor vehicle accident for example. There’s a longer list of the potential new headaches but those are the ones that we think about commonly that we need to include by history. If we can’t include by history, we do it by further testing when we see a patient.
For AVM and mass lesion, could you go into the historical elements that would raise concern for those two causes?
AVM, arteriovenous malformation causes throbbing headaches. We typically think of throbbing headaches as migraine and most of them will be due to migraine. Sometimes it could be from AVM- that's an important consideration- what doctors would call the differential diagnosis that is among the different possible explanations for a symptom. What would be different for AVM is that it could occur for the first time at an older age. Migraines usually start in adolescence or the early 20s. Headaches from AVM could start for the first time in the 30s or 40s. It is what's called commonly “side locked,” meaning that headache is always on the same side. Patients with migraine have headaches on one side, or unilateral. Over their lifetimes, it would typically alternate- it could be on the right side or the left. If someone says everyone of my headaches is always on the right, or side locked, that increases the possibility that it could be something more concerning, particularly AVM. Other features for AVM is you can have an aura, which is a visual symptom that could be due to a migraine. When it's due to a migraine, it typically lasts about 20 minutes to an hour. Sometimes patients with AVM, can have an aura, visual changes that could last for days, and what that represents is a small bleed, a sentinel bleed, at the site of the AVM that's persistent with aura-type symptoms or visual changes. These would be some of the things that would help to differentiate it from migraine, when a number of those features are present and possible explanations behind migraine. Brain tumor, the brain tumor headache, the most helpful thing would be if it gets worse over time. Long standing or old headaches are typically 30 stable years. Pattern doesn't change that much. Patients with brain tumor, theres a period of time when the symptoms very first start, they progress to the point when the tumor could causes some type of neurological compromise. It's fairly characteristic when in the range of about months- typically 1 or 2 months. If its evolving over hours to a a couple of days, it would be too fast and we wouldn't be thinking about brain tumor. If its evolving over a year or two and getting worse, it would be too slow. One exception is meningioma which is a benign tumor, brain which can progress slowly. Brain tumors which are malignant would typically get worse over the 1-2 month category. The severity may not necessarily even be as severe for patients if they do have old headaches for example migraine. Sometimes if it’s more cancerous or severe, is its gradually getting worse over a month or two would raise some flags for brain tumor. The actual descriptions would be if it were throbbing or not, located in the skull, those sorts of features can be variable, but the thing that tends to be persistent is this pace over time in the few month range. That's one of the most important factors on when to consider a brain tumor.
Three types of headaches
The main old headaches are longstanding headaches which would be migraine, tension-type, and cluster headaches. The most common of these are tension-type headaches. That's the kind that most of us have had for most of our lifetime because it tends to be less disruptive and people can often treat it with over the counter medicines. Patients less often come to see us due to tension-type headaches because it’s more manageable on its own. Migraine occurs less frequently than tension type headache and can be more disabling and require more professional assistance so people are more likely to see us because over the counter treatment may not be satisfactory. Features that distinguish migraine from tension-type headaches, most important ones would be whether it's throbbing or not- a migraine headache is typically throbbing and tension-type headaches are not, if it's on one side of the skull- migraines are most commonly unilateral-just on the right or left. There's also photophobia, which means looking into bright lights makes the headache worse. There’s also phonophobia, which makes migraines worse from loud sounds. Patients typically like to go to quiet rooms to avoid those stimuli. Things that tend to be most useful to distinguish is actually nausea. Nausea typically by definition should not occur with a tension headache. It’s fairly common with migraines. Somebody with recurring headaches over a prolonged period of time getting worse that doesn't sound like a new headache. Nausea with headaches, it's very likely to be migraine after further questioning. Other features would be family history which is often about two-thirds of the time in people with migraine. We can even go back to childhood. Adults with migraine frequently have been carsick as children.
Cluster headache is considerably less common than migraine and tension-type. The only common headache symptom is more common in men than women- it's about 6x more common in men than women. It has a very characteristic nature to it- it's always on one side. It can alternate, but any given episode has to be entirely unilateral- always on one side of the head. Its centered around the eye as opposed to the scalp such as the forehead or the temple. It’s excruciating and sometimes described as lancinating or electric shock-like pain. Sometimes a migraine patient would want to go to a quiet place. Sometimes patients with cluster headache will want to go in a comfortable position, but they can't find a position they can feel better in because of the severity of the pain. It typically lasts about an hour to an hour and a half for each episode. The other feature of cluster headache is what we call autonomic features. It refers to certain types of nervous system in the patient's body. The characteristic elements we don't see in other headaches symptoms is that it's also on the same side of the headache, it could be redness or tearing of the eye, runny nose, and somebody looking at a person with a cluster headache, the person on that side can be small. These are things we don't see with other headaches. It's difficult to diagnose when someone has one episode because there are other things that can do that. If a patient has cluster episodes multiple times, then we can be more confident. Where the term cluster comes from is that headaches cluster in times. A patient might have a few dozen of them over a couple of month and be headache free for a year, and then have another cluster for another couple months in their headache and that's where the term cluster comes from.
In thinking about the primary headaches- cluster, migraines and tension, how is the diagnosis being made from a clinical perspective?
These are clinical diagnoses, meaning the diagnosis is being made largely based on history. There's no test for these. The test would be simply to exclude other causes for headaches. Usually not required, but in some cases when there's uncertainty, there are other tests such as imaging, but the imaging would be normal in these three diagnoses. It’s really up to the clinician’s ability to take a careful history to tease out the different causes of headache. A typical examination unless somebody happens to have one a patient, which is typically normal so the exam does not add that much. The diagnoses are made by building a case. The more features that are present for say migraine or cluster, the more confident we can be of the diagnosis. Often times it's when we take a history it's evident within the first couple of sentences. We start talking to a patient within a minute or two, we have a pretty good idea of what the diagnosis is. The other features I mentioned are to be nothing else which we would be entertaining.
Treatment for primary headaches
Can you go a little bit into the treatment options for each type? I know you mentioned tension headaches being fit for the over-the-counter medicines. Could you go over what would be useful for each?
Tension-type headaches are often treated with over-the-counter (OTC) medications so Tylenol, Acetaminophen, Aspirin, and nonsteroidal anti-inflammatories such as Ibuprofen or Naproxen are all helpful for tension-type headaches. These are given as needed when the headaches actually occurs. It’s rare that when someone with tension type headache needs to be on chronic medication but there are prescription medicines they will sometimes use for tension-type headaches that are often frequent or disabling. Often times we can treat as needed, but since most of these are OTC, most patients have already explored it when they come into see us Migraine headaches are more complicated, but we can break it into different categories. There are certain complementary and alternative physical strategies which can help some patients- acupuncture or chiropractic medication can help mitigate migraines. Medications for migraine is broken into two treatments taken at the onset of the headache to shorten its duration or severity, or chronic daily medications to decrease someone's overall for a month for example. The two treatments would be among the same ones you can use for tension headaches such as NSAIDs or Aspirin. Acetaminophen does not usually work for migraines. There are prescription medications that are specific to migraines that can be used when those medicines are not effective. The prescription medicines would be ones that are specific to migraine, most commonly used ones are so called triptans which there are about a half dozen out and can be given in different formulations including a pill, a wafer that someone puts on their tongues and dissolves, a nasal spray and an injection someone would administer themselves at home. Theres also something called Ergotamine, which is another treatment for migraine that is used less commonly these days. For some patients whose migraines are typically disruptive or disabling or don't respond well to those two treatments which are very frequent, we can use a different number of options to decrease the total number of migraines which would long discussion with the provider to determine which would be the best option for different persons. Drug classes would include beta blockers, which are also used to treat other conditions besides migraine. Divalproex sodium which is an anti-seizure medicine which also prevents migraines and Topiramate which is another anti-seizure medicine that helps to prevent migraine and daily preventive use. There's a number of other medicines which are used less frequently. Patients with very disabling and chronic headaches like migraine which would be more than 15 days per month. There's a role for botulinum toxin injections in the muscles around the scalp and intracranial muscles. An injection would be 12 weeks to reduce the total number of migraines, but it’s only effective for chronic migraines and since it's expensive it usually requires prior authorization to get insurance to cover it. Those are some of the pharmacological strategies and in addition we talk to all patients with migraine about lifestyle modifications. There are certain healthy lifestyle modifications which can improve the course of migraines which include regular sleep schedules, regular meal schedules for example not skipping a meal, limiting caffeine to no more than two caffeinated drinks per day, and some patients, not all, know there are certain food triggers like red wine and chocolate. Those can be triggers and produce migraine, which is a very complicated discussion. There's a lot to go through in terms of how frequently they occur and how well patients respond to first steps of treatment.
Just to round out the rest of that discussion, can you talk about what options are available for someone with a cluster headache?
The treatments for cluster headache are quite different since it’s a different mechanism for migraine or tension-type headache. The same medicines that work for headache are among those used for migraine but there’s a difference. Most effective acute treatment for cluster headache given at the onset of headache is actually oxygen. A 100% oxygen given by facemask will abort cluster headache in a majority of patients with cluster. That's not always practical because someone cannot have it with them at work or when they are travelling, but if they have one at home, then that can be an acute treatment. Triptan which we talked about for migraines are also effective as an acute treatment when cluster headache occurs. Also the Ergots which I only briefly mentioned for migraines can be used as acute treatment for cluster headaches. The maintenance treatments for cluster are quite different than those for migraine. We do know that for some patients, corticosteroids, strong NSAIDs usually prednisone can be given in a burst at moderate to high dose with a taper of over 10-14 days at the onset of a cluster and will shorten the duration of a cluster. For maintenance therapy, that is chronic daily treatment in patients whose clusters occur frequently, patients can use two drugs which would be Topiramate and Divalproex sodium but other drugs can be used including: Verapamil which is a blood pressure medicine is also helpful here, and lithium, which is rarely used for bipolar disorder but can be used as a preventative treatment for cluster headache. It’s a very different repertoire of treatments.
Neck and sinus headaches
You’ve talked previously about other common causes of headache, specifically headaches related to the neck and sinus headaches. Given how common they are, can you talk about the treatments for those?
For sinus headache, many patients will misinterpret their headache- for example tension-type headaches being related to sinuses if they are in the front of the head. Sinus headaches are typically in the forehead, cheeks and sometimes radiating to the top of the head and those sinuses are involved. Sometimes they are made worse by bending forward. In many cases sinus headaches will have other sinus symptoms such as nasal congestion, chronic nasal discharge, the seasonal component makes it worse during pollen allergy season in the spring or fall. Treatments for sinus headaches depend on the underlying cause that are often allergic, treating the allergic component with cortisone, inflammatory sprays, antihistamines available over the counter, and sometimes sinus rinses can be helpful. A number of these products are available over-the-counter as well for sinus headaches. Some patients have tried these treatments before coming to the doctor. It’s rare that sinus headaches are disabling like migraines can be. They tend to be more annoying than disruptive or disabling.
Cervicogenic headaches which means headache from the neck-most common scenarios would either be in an older person who has osteoarthritis, or wear and tear in the neck or a person at any age who has been in a car accident with a whiplash type injury. These pains are sometimes described as burning on the scalp. Patients will feel it’s on the surface of the scalp wrapped inside their brain. It often starts in the back of their head and can radiate to the top of head and into the forehead and may be described as a burning, sharp, lancinating or tingling type pain. Different words can be used. Oftentimes, people who have neck pain with headache makes them more evident of what is going on but sometimes just the headache is the main feature and there's not a lot of neck pain and that can be more challenging to diagnose. Treatment options can be for the neck. If the neck is the culprit, you are actually treating the neck which could be by physical therapy for tender points and sometimes chiropractic manipulation, I always caution patients to be very careful because there can be injuries to the neck if it's not an experienced chiropractor. Acupuncture may be used for people who like to explore nonpharmacological treatments. Sometimes we’ll invite our pain doctors, which are usually anesthesiologists to do injections in the tender points or trigger points in the neck. Pain treatments are basically focused on the neck for patients with that condition.
More on Dr. Smetana
You’ve seen so many patients with headaches and have given us a great overview on how to think about it from a patient's perspective. What excites you about the future of managing headaches and the future of the research into the causes of headaches? Just in general, this is an open-ended question to give you a chance to talk about what excites you in terms of the management or understanding of headaches.
There hasn't been a whole lot new. The way we approach headache is pretty similar to what it was 10 or 20 years ago. What’s been different is that there's been a slightly expanded repertoire for preventative medicines for migraine. We didn't know for example, until the last decade or two about topiramate as an option to prevent migraines, Botulinum toxin injections which we’ve been doing for a number of years is another recent advance. I’ll say even less than 10 years ago. What we have learned with the different array of treatments for example for migraine or prevention is that they work for unknown mechanism. These drugs have completely different mechanism of action. What it tells us is that we actually don't know a lot about the underlying ideology because if we knew exactly what the cause was, the treatments would be completely focused on that. The fact that beta blockers used for blood pressure, seizure medicines, anti depressants are all helpful in preventing migraines really means that we don't know a lot about the ideology. There's a lot of theories that the treatment is mostly pure. That means we give it because it works not necessarily because we know exactly why it works. There's been some new advances in thinking about migraine. One of the new theories is there's a heightened sense of sensitivity than normal sensations in the scalp we call Allodynia. When someone touches their scalp or brushes against it, it feels pleasurable with a heightened awareness. Many patients with migraine have this and it's a relatively new observation that may potentially lead to new treatments. For the other headaches we talked about, not really much has changed and I’m not aware of much on the horizon that is likely to change in terms of how we manage those headaches.Disclaimer: The article does not replace an evaluation by a physician. Information on this page is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes.
Dr. Gerald Smetana
Beth Israel Deaconess Medical Center