Why are you experiencing headaches? Headaches can be one of the most annoying things we have to deal with, but they can also be completely debilitating and they’re one of the most common medical concerns for people. So in today’s article, we’re going to talk about the different types of headaches that you might be experiencing, some potential causes as well as some considerations to have when seeking treatment.

So hopefully by the end, we’ll have a better understanding of what’s going on with this thing. And of course, we’ll utilize the cadavers behind me to go over all the relevant anatomical awesomeness. So let’s jump right into this.

Primary Headache Vs Secondary Headache

So for us to better understand headaches, we first need to talk about what’s referred to as primary headaches versus secondary headaches. Headaches can be very annoying and take up a lot of time. But, they’re not caused by anything else other than the headache itself. And although these primary headaches can be all the way up to debilitating and really affect a person’s life, they’re not considered dangerous or life-threatening. Now, these secondary headaches are caused by an underlying disease, illness, or condition.

Let me give you a couple of examples. Say you had a headache from, say, a sinus infection or the cold or flu, or maybe something more serious like you had a headache from bacterial meningitis, a traumatic head injury, maybe even something like a brain tumor or even a ruptured aneurysm.

You can see there’s a wide range of potential causes of these secondary headaches and we would obviously want to focus on that underlying cause. So like if you were to treat bacterial meningitis, say, with like antibiotics, as you treat that condition, the headache should improve and resolve. Or if you heal from, say, a cold or the flu, eventually that headache will go away.

So we’re going to focus back on these primary types of headaches because we can’t blame them on, say, an underlying cause or condition.

Symptoms Of A Tension-Type Headache

Now, these primary headaches, essentially 90% of them, fall under three different categories or three different types of headaches. These are attention-type headaches, migraine headaches, and cluster headaches. But how do we tell the difference between these different types of primary headaches? Tension headaches usually occur due to tension in one’s neck, head, or shoulders.

Tension-type headaches are the most common of the primary headaches. They are mild to moderate in severity and most often bilateral, meaning they affect both sides of the head. Now, the pain is typically described as a nonpulsatile, dull band-like tension or pain around the head, sometimes even radiating down into the neck. And they can last for hours, even up to days in some cases. Now, a tention-type headache is known as a featureless headache.

But what do we mean by a featureless headache? Well, this means that they’re usually not associated with other symptoms like nausea, vomiting, visual changes, or even an aura like you might see in migraines. Headaches are common, and people usually get frustrated with them. However, headaches caused by neural networks are not as common, and people usually find them less frustrating.

And you also don’t usually see things like photophobia, which is light sensitivity, or phonophobia, which is sound sensitivity. Some people have said that they have tension headaches. This is an indication that something might be wrong. You should see a doctor check if there is a bigger issue.

People who might have a little light sensitivity or a little sound sensitivity, but you’re starting to get both of those. You’re knocking on the door of things like a migraine headache.

Why Muscles Were Originally Blamed For Tension Headache

But what are some of the potential causes of a tension-type headache? Now there are multiple factors that likely contribute to tension-type headaches, but based upon the name you might think, well, there’s got to be some sort of tension that’s contributing to these headaches, right? Well, that was the original thought or theory behind the cause of these headaches.

They were thought to be due to sustained or prolonged contractions in the muscles that we found in say, the neck, head, and face. So the idea was that because these muscles are attached to the skull, and not only that, their connective tissues blend and become continuous with the connective tissues of the skull, but if there were problems with them, they could cause pain that would radiate onto the head and create these tension headaches.

So for example, again, if we look at this muscle, the trapezius, you can definitely see it attaches to the skull and its connective tissues will blend and become continuous with those of the skull. And that’s only one muscle. There are multiple muscles.

For example, underneath there’s the splendidus catheteris muscle, a muscle on the side of the neck called the sternal clino mastoid attaches to the skull and its connective tissues become continuous. Even in the jaw, muscles have been implicated sometimes like the masseter attaching from the mandible or the jaw bone up onto the skull.

And those are only a few examples of some of the muscles. There are multiple muscles that attach from the neck to the head. Furthermore, if you look at people who have tension-type headaches, they will have pain and tenderness in these muscles.

So not necessarily they’re just sitting there in pain with all these muscles, but if you palpate and push on them or massage them, you can tend to elicit more pain and tenderness than you would in someone without tension-type headaches.

Where The Pain Is Coming From?

So you can see why problems with these muscles could have contributed to the original theory of what causes tension-type headaches. Now obviously I keep saying original theory because this is no longer thought to be the cause of tension-type headaches. You can definitely see some correlations there, but we’re not seeing direct causation. In other words, just because someone has sustained or prolonged muscle contractions in these muscles don’t mean they’re going to get a tension-type headache.

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But I still do think it’s fair for people to ask, why are people having pain in these muscles than with tension-type headaches? And this gets us into this discussion about kind of the chicken before the egg, which one came first? And when we look at things with tension headaches and what the data and research are starting to show is that there are these pain receptors called nociceptors that become sensitized in the connective tissues of the head of people who have tension-type headaches.

Now, remember, those connective tissues of the head are continuous with the connective tissues and tendonis attachments of those muscles we mentioned earlier.

And so the idea is that as those pain receptors or nociceptors of the connective tissues of the head get sensitized, the associated muscles or those muscles that are continuous, their pain receptors also get sensitized, helping to explain why you can have pain in both areas.

Do We Know What Is Causing/Triggering The Pain

But what is causing the sensitivity of these nociceptors? Well, what’s frustrating is we don’t totally know. Again, we cannot definitively say that it’s a problem originating in these muscles from say, sustained or prolonged contractions. We also can’t definitively say it’s purely originating from the connective tissues of the head and radiating down to these muscles.

However, there is some useful information that we can draw from and that is the most commonly reported precipitating factors for tension-type headaches are things like stress and mental tension.

How Do You Treat Tension-Type Headaches

So when a patient comes into the clinic and I suspect they have a tension-type headache, I talk to them about stress and what’s going on in their lives. And I often recommend relaxation techniques and that can be anything from deep breathing, meditation, and even things like light stretching of the muscles and even gentle massage.

And I know this is anecdotal, but I’ve had patients have improvement from those techniques and they’re so non-invasive that I almost recommend them to all patients with tension-type headaches because you don’t have a lot of drawbacks to trying these types of techniques.

We can also step up to things like over-the-counter analgesics and we have pretty clear data that shows that things like Tylenol, also known as Acetaminophen and Ibuprofen, do help reduce the pain of tension headaches compared to placebo.

And a lot of the data shows that Ibuprofen is a little bit better than say, Tylenol slash acetaminophen. And if those pain medications don’t work, you can often step up to combination medications, things like Excedrin, for example, Excedrin, is a combination medication that contains aspirin, caffeine, and even Tylenol.

And you do have to be careful when you start stepping up to some of these medications because you can get what’s called a medication overuse headache. And so it’s again always wise to talk to your medical provider when you’re starting to throw in medications to help treat your headaches. And that goes for even some of the other headaches that we’re going to talk about here.

Symptoms Of Migraine

The next type of primary headache is the migraine. Migraine headaches are most commonly unilateral. They can affect both sides of the head but most commonly one side of the head. And the pain is usually described as this pulsatile throbbing type of pain. Now, this is definitely not a featureless headache that we saw with tension-type headaches.

They’re often associated with features like nausea, vomiting, light sensitivity, sound sensitivity, and even physical activity can aggravate the pain of a migraine. I get these every once in a while and I hate them even when I sneeze and cough. That can aggravate the pain of a migraine. Now there are often neurological symptoms that can also be associated with migraines. Things like visual changes and an aura.

The 4 Phases Of A Migraine

And these types of things can be explained with the idea that a migraine is a phasic headache in other words it has four phases that are associated with it. These four phases are referred to as the premonitory phase followed by the aura phase, then the actual headache phase, and then the postdrome or postromal phase.

Now, this first phase, or the premonitory phase is often difficult for people to notice or pick up on because it can occur one to two days before the pain of the headache even starts. And it also is associated with symptoms like irritability, food cravings, and even more frequent yawning has been reported as part of the premonitory phase. And who doesn’t occasionally experience symptoms like that?

The second phase is the aura phase and an aura is defined as a fully reversible neurological symptom. And not everybody experiences or at least notices the aura phase. But there can be different types of auras. Like the visual aura is the most common and that’s when you get blurred or lines or specs in your vision you’re going to have a sensory aura or on one side of the body, you could’ve to feel tingling.

And then there’s also a language aura where you could have difficulty with speaking and even a motor aura which would be weakness on one side of the body.

Again that visual aura is the most common. Then the third phase is the actual headache phase which we talked about, that unilateral pulsatile pain. And that fourth phase, the postdrome or postromal phase is kind of this residual effect of the headache the next day. So the main portion of the headache has resolved.

But you may notice that when you turn your head or when you cough or sneeze, you’re reminded that there are still some residual effects or pain there and you might still feel a little bit off the next day. And that postdrome phase can be explained by sensitization of this nerve called the trigeminal nerve.

Causes Of The Migraine And The Trigeminal Nerve

Now, this trigeminal nerve is thought to be a major player in the cause of migraine headaches. And there are certain sensory pathways, specifically pain, and nociceptive pathways within the trigeminal nerve that are thought to be more easily activated or sensitized in people that have migraines versus people who don’t. And again, that sensitization can linger on until the day after which we mentioned in that post-ground phase.

And what can often cause the activation or the sensitivity of this trigeminal nerve are certain migraine triggers. Now the trigeminal nerve is one of twelve cranial nerves. It’s the fifth cranial nerve and it comes directly off the brain stem it’s often referred to as the great sensory nerve of the face. That’s because it brings in the sensation of the face.

It even hooks up to muscles that move the jaw and makes connections to cerebral blood vessels or blood vessels of the brain and even connective tissue structures that surround the brain like the dura mater.

And the reason I bring all that up is that those pathways can explain the characteristics of the pain and even the location of where people get this migraine headache.

Common Locations Of A Migraine Headache

Now, one of the most common locations of a migraine headache is around the forehead and the eye. And again, that can be explained by one of the major divisions of the trigeminal nerve commonly being affected. Now think, tri means three, there are three divisions or nerve branches coming off of the main trigeminal nerve, the ophthalmic division or nerve, the maxillary, and the mandibular.

Now ophthalmic refers to the eye and this ophthalmic division or nerve branch wouldn’t affect these tissues or control or innervate the area around the forehead and the eye. And again, can explain why there’s a pain in that area. Now, this is not the only potential location of pain for the migraine, but I am going to pause there for one major reason.

Treatment Of A Migraine

Now we’ve got to talk about the third type of primary headache, and that is cluster headaches.

But before I completely jump into cluster headaches, I do want to mention some potential treatment options for migraines. There is some crossover with treatment for tension-type headaches and migraines. You could try to start with Tylenol or Acetaminophen. Granted, most people with migraines will say Tylenol doesn’t do much. And so then we can step up to say, like ibuprofen. And if ibuprofen alone doesn’t work, then we’re getting into those combination medications again.

And those tend to work better with that combination of caffeine, aspirin, and even Tylenol. And if we need to step up even further, then we’re knocking on the door of prescription drugs. There are things that we often refer to as trypsins. There’s a medication called Sumatriptan, which is a prescription drug for migraines. And of course, in that case, if we’re getting to prescription medications, we’re dealing with your medical provider. And again, it’s always wise, as I mentioned, with tension-type headaches to be evaluated and work with them with certain medications that you might use to treat this type of headache.

Possible Causes Of A Cluster Headache

Cluster headaches are the least common of the three primary headaches that we’ve talked about, and their cause isn’t really known.

But there is some belief that during a cluster headache, there’s some activation of the structure in the center of the brain called the hypothalamus. And that in turn, the hypothalamus will activate certain autonomic pathways during this headache. But what’s an autonomic pathway? Well, the autonomic division or portion of your nervous system controls things automatically at a subconscious level, so you don’t have to think about it.

It hooks up and controls things like the smooth muscle of your digestive tract and even your blood vessels. The pupils of your eyes actually have smooth muscle so they can constrict and dilate. The autonomic nervous system also hooks up to various glands throughout the body. And all of this is relevant because of the symptoms that come with a cluster headache.

Symptoms Of A Cluster Headache

Cluster headaches come suddenly, and the pain is described as stabbing and severe. These are unilateral, so one-sided in or around the eye and or the temporal region. Now, because of their sudden onset and severity, sometimes these can be mistaken for more serious life-threatening headaches. But there are some other associated symptoms that can help us distinguish the cluster headache.

And that’s where our autonomic discussion comes in because these cluster headaches are associated with certain autonomic symptoms. And these symptoms can include things like Ptosis, which is drooping of the eyelid, and meiosis, which is constriction of the pupil.

Conjunctival injection, which is bloodshot eyes, or when the blood vessels of the conjunctive of the eyes start to expand or dilate, you get lacrimation, which is the production of tears or tears. You can also get Rhinoa, which is a fancy pants name for saying a runny nose. Also, congestion, facial swelling, or I should say periorbital swelling. Which is swelling around the eye and even facial sweating. Now, each individual episode or attack typically lasts anywhere from 15 minutes up to 3 hours.

The “Cluster” In Cluster Headache

But this is where the cluster part starts. These individual headaches or attacks can reoccur as frequently as once every other day, up to eight times per day. So you can see we’re starting to form these clusters. And these cluster periods can last days weeks, or even up to months.

And after these cluster periods, they are generally followed by a period of remission with no headaches. And these periods of remission can sometimes last over a year.

Treatment Of A Cluster Headache

So obviously, these cluster headaches and cluster periods would suck. So it would be nice to treat these as effectively as possible. And the first line of treatment for this acute portion of the acute phase of a cluster headache is actually oxygen. Yes, they put people on 100% oxygen with a nonrebreather mask and this is pretty effective. We don’t know exactly why, but giving oxygen to patients with cluster headaches helps reduce the headaches.

Another first-line treatment is trypsin that I mentioned earlier in the article called Sumo Tryptin which has some crossover to migraine treatment, but those are also effective medications. And sometimes people will get both oxygen and Sumo Trypton in this acute phase. Now, I say this acute phase because there is this concern about how long is this cluster period going to last. So there are also preventative medications. There are two medications that we usually look into and that is one called Verampa Meal sometimes these are anti-inflammatory steroids such as Prednisone.

Now you’ll use one of the drugs, or sometimes both, depending on the person’s pattern of clusters, and how long they last. The severity, and a lot of different individual factors, which obviously again, you’d want to go over with your medical provider.