More than 45 million Americans suffer from recurring headaches. But only a small fraction of these people ever seek a doctor's attention because most headaches disappear on their own or with the help of an over-the-counter pain reliever, relaxation, or a good night's sleep. But what about headaches that are severe, occur often, or are unresponsive to these efforts?
Although headaches are rarely omens of more ominous disease, distinguishing a harmless headache from a dangerous one can be difficult, in part, because serious headaches are not necessarily severe or frequent.
In general, talk with your doctor if you're having a headache on a weekly basis, if your headaches interfere with your ability to function, or if they change in any particular way. Most likely, your headaches aren't a symptom of anything serious, but the peace of mind justifies the time and expense of a medical evaluation. Table 2 is a guide to situations where you should call your doctor sooner rather than later.
Table 2: When a headache requires immediate medical attention |
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Situation |
Which might mean |
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A headache that's accompanied by a fever and a stiff neck. |
Meningitis, an inflammation of the membrane that covers the brain. A CT scan and evaluation of spinal fluid (obtained via a spinal tap, in which fluid is drawn from the lower back region of the spine) can confirm or rule out this diagnosis. |
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A headache accompanied by neurological impairment (for example, difficulty speaking or walking, paralysis, or double vision). |
Bleeding, a blood clot, abscess, tumor in the brain. Imaging tests, such as a CT scan or MRI, are required to evaluate the situation. |
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A headache that feels like a blow to the head (also known as a thunderclap headache). |
Bleeding around the brain. A CT scan and a spinal tap are often necessary to make a diagnosis. |
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A headache that slowly but relentlessly gets worse over weeks or months. |
Brain tumor. Evaluation by a CT scan or MRI may be needed. |
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A headache with constant, severe, throbbing pain in the temple region, particularly in people over age 60. |
Giant-cell arteritis (see “When it hurts to the touch: giant-cell arteritis”). Blood tests and a biopsy are needed to confirm the diagnosis. |
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A headache that occurs daily, especially if it strikes in the back of the head, is present on awakening, and improves when you get out of bed. |
High blood pressure. Have your blood pressure measured and schedule follow-ups as necessary. |
The typical office visit for headaches may include a medical history and a physical examination. Most doctors will ask some detailed questions about your headaches (see “What your doctor will want to know”) and may order some basic laboratory tests.
What your doctor will want to knowBecause common headaches have few, if any, measurable effects on the body, tests aren't likely to turn up much in the way of helpful information, so it is helpful to provide your doctor with as many details about your headaches as you can. Before an appointment, you may find it useful to jot down the answers to these questions.
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The physical exam part of your visit will be determined by your particular headache symptoms. In some cases, your doctor may decide to have a careful look inside your eyes with an ophthalmoscope. Increased pressure in the head, which can be a sign of a brain tumor, can cause swelling of the optic disk. An ophthalmoscope examination is used to check for such swelling. In some people, migraine and tension headaches produce telltale signs such as tender areas, known as "trigger spots", at the back of the head and spasms in the neck and shoulder muscles, which your doctor may check for. But in most people who have tension or migraine headaches, the physical examination doesn't turn up anything unusual.
That's why an accurate, detailed description of your symptoms is invaluable to your physician. Describe when your headaches began occurring; what they feel like; particular situations that seem to prompt or worsen them; and the location, frequency, intensity, and duration of the pain. It's also worthwhile to keep a log of your headaches (see “A headache diary”).
Other important information includes additional symptoms linked to your headaches: what's helped relieve your pain in the past, which prescription and nonprescription medications you currently take, and if other family members have problem headaches. A broad discussion about your life, focusing on stresses at home or work and the impact of your headaches, can also help your doctor better plan your treatment.
It is a good idea for anyone over age 40 who's bothered by headaches to also schedule an appointment for a glaucoma check. This condition, which is caused by elevated pressure in the eye, can cause headache-like pain. It's treatable but can result in decreased vision if it goes undetected. Because eyestrain from squinting can cause regular headaches, a thorough eye exam may also reveal that something as simple as new glasses might alleviate your pain.
Considering the prevalence of headaches and the long list of potential causes, remarkably few people require any diagnostic tests. People with a long history of headaches that haven't changed much in intensity or frequency are less likely to need additional tests than individuals just starting to experience headaches or whose headaches have gotten worse. Pain that occurs consistently in the same location or on one side of the head — which could result from an underlying medical condition, such as a tumor or a blood vessel abnormality — may also warrant a more detailed workup. On the other hand, a headache that regularly shifts from one side to the other may not, since this suggests a less ominous cause such as stress or fatigue. No tests are needed for obvious tension or migraine headaches. Your doctor will discuss which, if any, of the following tests may be required depending on your headache symptoms.
CT scans are taken by a special x-ray machine. Rather than sending one wide x-ray beam through your body, this machine sends out many beams. It measures the x-ray beams (and how much they change after passing through your body) and stores the information. Using measurements from many angles, a computer generates detailed cross-sectional pictures of your body.
The CT scan provides a much clearer picture of your head than a regular x-ray. The test is painless and can help identify tumors, bleeding, areas of damaged brain tissue, and even sinus infections. It takes approximately 10 minutes. In some cases, a contrast dye is administered intravenously to define the brain structures more clearly.
Although an MRI creates an image similar to that produced by a CT scan, the technique is quite different. Rather than using x-rays, the MRI relies on a strong magnetic field. The affected organs give off minute electromagnetic waves in frequencies that differ according to the type of tissue involved. A computer tallies the vibrations and uses this data to create cross-sectional images on many different planes. These remarkably detailed pictures can show the difference between brain tissue and tumors and highlight areas of the brain that have been damaged by a stroke or other neurological conditions.
For an MRI the patient lies inside a machine that can be likened to a large, well-lit tube. The process is noisy, so the technician will provide ear protection. Some people feel claustrophobic inside the device, but MRI machines of a more open design are available in some facilities. The procedure takes 20-45 minutes. If intravenous dye is needed to enhance the image, it's usually given halfway through the scan.