Overview
Headache is one of the most common neurological symptoms. The majority are primary headaches, meaning they are not caused by another condition. Tension headache is most common. Migraine affects about 1 in 7 people and can be debilitating. Distinguishing headache types guides effective treatment.
How common is it?
Tension headaches affect nearly everyone at some point. Migraine affects about 15% of the UK population. Cluster headaches are less common, affecting about 1 in 1,000.
Causes and risk factors
Primary headaches arise from activation of pain-sensitive structures in the head and neck. Tension headaches involve muscle tension and central pain sensitisation. Migraine involves complex brain neurological changes including vascular and cortical spreading depression.
Common risk factors
- Stress and muscle tension
- Poor posture
- Dehydration
- Sleep disruption
- Hormonal changes (particularly in women)
- Certain foods and drinks: caffeine, alcohol, aged cheese
- Bright lights, loud noises, strong smells (migraine triggers)
- Weather changes
Symptoms
- Tension headache: bilateral dull pressure or tightening around the head
- Migraine: typically one-sided, pulsating, moderate to severe, with nausea, sensitivity to light and sound
- Aura before migraine in about 30%: visual disturbances, zigzag lines, or numbness
- Cluster headache: excruciating pain around one eye with watering, lasting 15 to 180 minutes
When to see a doctor
See a doctor urgently for the worst headache of your life, headache with fever and stiff neck, headache with weakness or vision change, or headache after head injury. These may indicate serious underlying causes.
Diagnosis
Most headaches are diagnosed clinically. CT or MRI brain scan is done for red flag headaches, new persistent headache in someone over 50, or atypical features. Blood tests exclude infection and inflammation.
Treatments
Acute analgesics and triptans
Simple analgesics (paracetamol, ibuprofen) for mild to moderate headache. Triptans (sumatriptan, rizatriptan) are specific for migraine attacks and are highly effective when taken early.
Preventive migraine treatment
For frequent migraines (3 or more per month): propranolol, amitriptyline, topiramate, or the newer CGRP monoclonal antibodies (erenumab, fremanezumab) taken monthly.
Lifestyle and trigger management
Regular sleep, regular meals, adequate hydration, stress management, and a migraine diary to identify personal triggers can significantly reduce headache frequency.
Self-care and lifestyle
- Keep a headache diary to identify triggers and pattern
- Maintain regular sleep, eating, and hydration routines
- Avoid overuse of pain relief (more than 10 to 15 days per month causes medication overuse headache)
- Regular aerobic exercise reduces migraine frequency
Prevention
Identifying and managing personal triggers, maintaining regular routine, preventive medication for frequent migraines, and treating contributing conditions such as poor posture and sleep apnoea.