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Headaches - A Guide

Many people in the UK get headaches regularly, making them one of the most common health issues

Tension Headaches
Migraines
Cluster Headaches
Medication and Painkiller Headaches
Hormone Headaches

Overview

In many cases, you can treat your headaches at home with over-the-counter painkillers and lifestyle changes, such as getting more rest and drinking enough fluids.

However, it's a good idea to see your GP if your headaches aren't relieved by over-the-counter treatments, or if they're so painful or frequent that they affect your daily activities or are causing you to miss work.

Some of the main types of headaches and common causes of headaches are described below.

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Tension headaches

A tension-type headache is the most common type of headache and the one we think of as a normal, everyday headache. 

It may feel like a constant ache that affects both sides of the head. You may also feel the neck muscles tighten and a feeling of pressure behind the eyes.

A tension headache normally won't be severe enough to prevent you doing everyday activities.

It usually lasts for 30 minutes to several hours, but can last for several days.

Who gets tension headaches?

Most people are likely to have experienced a tension headache at some point. They can develop at any age, but are more common in teenagers and adults. Women tend to suffer from them more commonly than men.

It's estimated that about half the adults in the UK experience tension-type headaches once or twice a month, and about 1 in 3 get them up to 15 times a month.

About 2 or 3 in every 100 adults experience tension-type headaches more than 15 times a month for at least three months in a row. This is known as having chronic tension-type headaches.

When to seek medical help

There's usually no need to see your GP if you only get occasional headaches. However, see your GP if you get headaches several times a week or your headaches are severe.

Your GP will ask questions about your headaches, family history, diet and lifestyle to help diagnose the type of headache you have.

You should seek immediate medical advice for headaches that:

  • come on suddenly and are unlike anything you've had before
  • are accompanied by a very stiff neck, fever, nausea, vomiting and confusion
  • follow an accident, especially if it involved a blow to your head
  • are accompanied by weakness, numbness, slurred speech or confusion

These symptoms suggest there could be a more serious problem, which may require further investigation and emergency treatment.

What causes tension headaches?

The exact cause of tension-type headaches isn't clear, but certain things have been known to trigger them, including:

  • stress 
  • squinting
  • poor posture
  • tiredness
  • dehydration
  • missing meals
  • lack of physical activity
  • bright sunlight
  • noise
  • certain smells

Tension-type headaches are known as primary headaches, which means they're not caused by an underlying condition. Other primary headaches

How are tension headaches treated?

Tension-type headaches aren't life-threatening and are usually relieved by painkillers or lifestyle changes.

Lifestyle changes

Relaxation techniques can often help with stress-related headaches. This may include:

  • yoga
  • massage
  • exercise
  • applying a hot flannel to your forehead and neck

Painkillers

Painkillers such as paracetamol or ibuprofen can be used to help relieve pain. Aspirin may also sometimes be recommended.

If you're taking these medications, you should always follow the instructions on the packet. Pregnant women shouldn't take ibuprofen during the third trimester, as it could risk harming the baby, and children under 16 shouldn't be given aspirin.

Medication shouldn't be taken for more than a few days at a time and medication containing codeine, such as co-codamol, should be avoided unless recommended by a GP.

Painkiller headaches

Taking painkillers over a long period (usually 10 days or more) may lead to medication-overuse headaches developing. Your body can get used to the medication and a headache can develop if you stop taking them. 

If your GP suspects your headache is caused by the persistent use of medication, they may ask you to stop taking it. However, you shouldn't stop taking your medication without first consulting your GP.

Preventing tension headaches

If you experience frequent tension-type headaches, you may wish to keep a diary to try to identify what could be triggering them. It may then be possible to alter your diet or lifestyle to prevent them occurring as often.

Regular exercise and relaxation are also important measures to help reduce stress and tension that may be causing headaches. Maintaining good posture and ensuring you're well rested and hydrated can also help.

Guidelines from the National Institute for Health and Care Excellence (NICE) states that a course of up to 10 sessions of acupuncture over a 5-8 week period may be beneficial in preventing chronic tension-type headaches.

In some cases, an antidepressant medication called amitriptyline may be prescribed to help prevent chronic tension-type headaches, although there's limited evidence of its effectiveness. This medication doesn't treat a headache instantly, but must be taken daily for several months until the headaches lessen.

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Migraines

Migraines are less common than tension headaches. They're usually felt as a severe, throbbing pain at the front or side of the head. Some people also have other symptoms, such as nausea, vomiting and increased sensitivity to light or sound.

Migraines tend to be more severe than tension headaches and can stop you carrying out your normal daily activities. They usually last at least a couple of hours, and some people find they need to stay in bed for days at a time.

Most people can treat their migraines successfully with over-the-counter medication. But if they're severe, you may need stronger medication that's only available on prescription. This may be able to relieve and prevent your migraines.

Read more about migraines.

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Cluster headaches

Cluster headaches are excruciating attacks of pain in one side of the head, often felt around the eye.

They're estimated to affect around 1 in 500-1,000 people. Anyone of any age can be affected, but they're more common in men and tend to develop in people over the age of 20.

It's not clear exactly what causes cluster headaches, but they've been linked to activity in part of the brain called the hypothalamus. People who smoke seem to be at a higher risk. Some cases also appear to run in families, which suggests there may be a genetic link.

For most people, cluster headaches occur in recurrent "bouts" over several weeks (typically 4-12 weeks) followed by headache-free periods (remission) that often last for months, or sometimes years.

Cluster headache bouts may occur every year over many years and may be lifelong. In general, they become less frequent over time. Treatment is available to control them.

Symptoms of a cluster headache

Cluster headaches begin suddenly and without warning. The pain is very severe and is often described as a sharp, burning or piercing sensation on one side of the head. The pain is typically felt around the eye, temple and sometimes face, and typically recurs on the same side for each attack.

Often people feel restless and agitated during an attack because the pain is so intense, and may react by rocking, pacing or banging their head against the wall.

They commonly also have at least one of the following associated symptoms:

  • a red and watering eye 
  • drooping and swelling of one eyelid
  • a smaller pupil in one eye
  • a sweaty face
  • a blocked or runny nostril
  • a red ear

These attacks generally last between 15 minutes and three hours, and typically occur between one and eight times a day.

Pattern of attacks

Cluster headaches usually occur every day, in bouts lasting several weeks or months at a time, before they subside. Remission will often follow, which sometimes lasts months or years before the headaches start again.

During a cluster headache bout, the headaches often occur at the same time each day. For example, people often wake up with a headache within a couple of hours of going to sleep. The attacks also seem to recur at similar times of the year, most often in spring and autumn.

Some people notice certain triggers for their headaches during a period of attacks, such as:

  • drinking alcohol
  • warm temperatures
  • exercise
  • strong smells, such as perfume, paint or petrol

Cluster headache bouts separated by a remission period of one month or more are known as episodic cluster headaches. Those separated by a remission period of less than one month, or present for at least 12 months without remission, are known as chronic cluster headaches.

About 10-20% of cluster headache cases are chronic.

Seeking medical advice

You should see your GP as soon as possible the first time you experience what you think may be a cluster headache.

They will ask you about your symptoms and may refer you for tests. In some people a brain scan is needed to exclude other conditions that can have similar symptoms to cluster headaches.

Typically, in cluster headaches the brain scan is normal and the diagnosis is made on the basis of your symptoms without the need for tests.

If you're diagnosed with cluster headaches, you will usually see a specialist such as a neurologist (a specialist in conditions affecting the brain and nerves) to talk about your treatment options.

Treating cluster headaches

Cluster headaches aren't life threatening, but they can cause significant suffering and severely affect your quality of life, so it's important to see someone who is familiar with the known effective treatments for the condition.

The headaches can't be treated with over-the-counter painkillers such as paracetamol, as these are too slow to take effect. You'll need to have one or more specialist treatments instead.

Three main treatments are available to relieve pain when taken soon after a cluster headache starts. These are:

  • sumatriptan injections, which you can give yourself up to twice a day
  • sumatriptan or zolmitriptan nasal spray, which can be used if you would prefer not to have injections
  • oxygen therapy, where you breathe pure oxygen through a mask

These treatments usually relieve the pain of a cluster headache within 15-30 minutes.

Preventing cluster headaches

Your doctor may also prescribe medication to prevent cluster headaches during a headache bout. This involves starting treatment as soon as the headaches begin and continuing it until the bout is thought to have stopped.

The main treatment recommended to prevent cluster headaches is a medication called verapamil, which is taken as a tablet several times a day. You'll need to be monitored by the doctor treating you with a test called an electrocardiogram (ECG) while taking this medication, as it can cause heart problems in some people.

Alternative treatments may be considered if verapamil is not effective. These may include corticosteroids, lithium medication and occipital nerve blocks (injections of a local anaesthetic into the back of the head).

There is now also a promising new treatment that uses a device to stimulate a nerve in the neck to prevent cluster headaches. This is known as external vagal nerve stimulation.

Preventative treatments can vary in effectiveness from person to person. A few different treatments may need to be tried before your attacks are under control.

Support groups

Living with cluster headaches can be extremely difficult, so you may find it useful to seek further advice and support from organisations such as OUCH (UK).

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Medication and painkiller headaches

Painkillers are a good way to relieve headaches, but if you take them more than two or three times a week, they could become the cause of your headaches.

Up to 1 in 10 people who have frequent headaches do so because they take painkillers too often, says Dr Fayyaz Ahmed, consultant neurologist at Hull Royal Infirmary.

“Around 5% of the patients in my headache clinic have what we call medication-overuse headaches, from taking painkillers regularly over a long period. 

"This statistic is probably even higher in the general population, with 5-10% of people with headaches getting them from taking too many painkillers."

Painkiller headaches

Painkiller, or rebound, headaches are frequent or daily headaches that develop after taking painkillers for tension headaches or migraines over several months.

Strangely, painkiller headaches only become a problem for people who take painkillers to treat headaches. They don’t happen to people who take painkillers for long periods for other painful conditions, such as arthritis and back pain.

What causes painkiller headaches?

Painkiller headaches are usually caused by taking painkillers for too long and not because of exceeding the recommended dose.

“Most people who get medication-overuse headaches aren’t taking more than the recommended dose on the painkiller packet,” says Dr Ahmed.

“The problem begins when you take advantage of the recommended dose to take painkillers for long periods, often for months on end.

“If you take painkillers for your headaches more than twice a week for more than three months, you'll be at very high risk of getting rebound headaches,” says Dr Ahmed.

What happens is that your body gets used to the painkillers.

A rebound headache develops if you don’t take a painkiller within a day or so of the last dose. You assume it’s just another tension headache or migraine and take a further dose of painkiller.

When the effect of the painkiller wears off, another rebound headache develops and the cycle continues.

Some people even start to take painkillers every day to prevent headaches, which only makes matters worse.

Painkillers to avoid

All the common painkillers available from chemists can cause this problem. They include:

  • codeine
  • paracetamol
  • non-steroidal anti-inflammatory drugs (NSAIDs) – painkillers such as aspirin and ibuprofen 
  • a group of specific anti-migraine medicines known as triptans, such as sumatriptan

However, some painkillers are more likely to cause medication-overuse headaches than others.

“Painkillers containing codeine are most likely to lead to overuse headaches,” says Dr Ahmed. His advice to prevent painkiller headaches is:

  • Don't take painkillers for headaches on more than two days in each week.
  • Don’t take painkillers for headaches for two or more consecutive days.
  • Avoid codeine or codeine-containing painkillers such as Syndol and Solpadeine.

Treating painkiller headaches

The treatment for medication-overuse headaches is simple – stop taking painkillers.

According to Dr Ahmed, if you've been dependent on painkillers for months rather than years, the best approach is to stop abruptly.

“Your headaches will probably get worse immediately after stopping, and you may feel sick or sleep badly, but after 7 to 10 days, when the painkillers are out of your system, you'll feel better,” he says.

If you’ve been getting painkiller headaches for several years as a result of taking codeine-containing products, it can be dangerous to stop abruptly. Instead, gradually reduce the number of painkillers you take. This is best done under the supervision of a doctor.

Preventing painkiller headaches

Once your painkiller headaches have stopped and your tension headaches or migraines are back to normal, you can start to use painkillers again as you need them.

“Around 70-80% of people with medication-overuse headaches manage to stop regularly taking painkillers and feel much better as a result. The other 20-30% relapse over time and may have to go through withdrawal periods repeatedly,” says Dr Ahmed.

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Hormone headaches

Most headaches in women are caused by hormones. At least 5 million women experience hormone headaches each month, say researchers.

According to Dr Anne MacGregor, formerly of the National Migraine Centre, more than half of women who get migraines notice a link with their periods. These so-called "menstrual migraines" tend to be particularly severe.

“Migraine is most likely to develop in either the two days leading up to a period, or the first three days during a period. This is because of the natural drop in oestrogen levels at these times. The attacks are typically more severe than migraines at other times of the month and are more likely to come back the next day,” she says.

Periods aren’t the only trigger of hormone headaches. Other causes include:

  • The combined oral contraceptive pill. Some women find their headaches improve while they’re on the pill, but others report more frequent attacks, especially in the pill-free week when oestrogen levels drop.
  • The menopause. Headaches usually worsen as you approach the menopause, partly because periods come more often and partly because the normal hormone cycle is disrupted.
  • Pregnancy. Headaches can get worse in the first few weeks of pregnancy, but they usually improve or stop completely during the last six months. They don’t harm the baby.

Signs of hormone headaches

It’s worth keeping a diary for at least three menstrual cycles to help you check whether your migraines are linked to your periods. If they are linked, a diary can help to pinpoint at what stage in your cycle you get a migraine.

The Migraine Trust has an online headache diary, which may be a useful tool.

Self-help tips for hormone headaches

If keeping a diary reveals that your headaches develop just before your period, you can take these steps to help prevent a migraine:

  • Eat small, frequent snacks to keep your blood sugar level up. Missing meals or going too long without food can trigger attacks. Have a small snack before going to bed and always eat breakfast.
  • Have a regular sleep pattern. Avoid too much or too little sleep.
  • Avoid stress. If this proves difficult, find ways to deal with stress, such as taking regular exercise and using relaxation strategies. 

Treatments for hormone headaches

Oestrogen therapy

If you have regular periods, menstrual migraines may be eased by taking extra oestrogen before your period is due and for a few days during your period.

A doctor has to prescribe oestrogen supplements, which can be a gel to rub into your skin or a patch to stick on. 

Migraine treatments

Your doctor can also prescribe anti-migraine medicines for you to take around the time of your period. These don’t contain hormones, but they can help stop the headaches developing. They include tablets called triptans and a type of painkiller called mefenamic acid.

Continuous contraceptive pills

Talk to your doctor if you think your contraceptive pills are making your migraines worse. If you have headaches during the days you don't take the pills, you can avoid the sudden fall in oestrogen by taking several packs continuously without a break.

Read more about the contraceptive pill.

Hormone replacement therapy

The hormone changes that happen as women approach the menopause mean that all types of headache, including migraines, become more common.

Hormone replacement therapy (HRT) can be helpful to treat hot flushes and sweats, but if you have migraines it’s best to use patches or a gel, as these types of HRT keep hormone levels more stable than tablets and are less likely to trigger migraines.

Other causes of headaches

Headaches can also have a number of other causes, including:

  • drinking too much alcohol
  • head injury or concussion
  • a cold or flu
  • temporomandibular disorders – problems affecting the "chewing" muscles and the joints between the lower jaw and the base of the skull
  • sinusitis – inflammation of the lining of the sinuses
  • carbon monoxide poisoning
  • sleep apnoea – a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing

Click on the links above for more information about these conditions.

Could it be something serious?

In the vast majority of cases, a headache isn't a sign of a serious problem. But, rarely, it can be a symptom of a condition such as a stroke, meningitis, or a brain tumour.

A headache is more likely to be serious if:

  • it occurs suddenly and is very severe – often described as a blinding pain unlike anything experienced before
  • it doesn't go away and gets worse over time
  • it occurs after a severe head injury
  • it's triggered suddenly by coughing, laughing, sneezing, changes in posture, or physical exertion
  • you have symptoms suggesting a problem with your brain or nervous system, including weakness, slurred speech, confusion, memory loss, and drowsiness
  • you have additional symptoms, such as a high temperature (fever), a stiff neck, a rash, jaw pain while chewing, vision problems, a sore scalp, or severe pain and redness in one of your eyes

If you're concerned that your headache might be serious, you should seek immediate medical advice. Contact your GP or NHS 111 as soon as possible, or go to your nearest accident and emergency (A&E) department.

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