Headaches: Types, Causes and When to Worry

Types of headache

Primary headaches

Secondary headaches

• Medication overuse headache: from taking pain relievers too often, usually on 10 to 15 or more days a month.
• Sinus headache: facial pressure with a blocked nose and thick discharge during sinusitis. Many self-diagnosed "sinus headaches" are actually migraine.
• Post-lumbar puncture headache: worse upright and better lying down. See headache after lumbar puncture.
• Infections: flu, COVID-19, meningitis and encephalitis.
• High blood pressure: only severe rises cause headache.
• Giant cell arteritis: new headache in people over 50 with scalp tenderness. See giant cell arteritis.
• Bleeding in the brain: sudden "thunderclap" headache, as with subarachnoid hemorrhage.
• Raised pressure in the skull: from tumors or idiopathic intracranial hypertension, worse lying down and in the morning.
• Others: caffeine withdrawal, hangover, dehydration, sleep apnea, neck problems, TMJ disorders and head injury.

Frontal headaches: causes of pain in the forehead

A frontal headache is felt across the forehead or temples. Common causes:

• tension-type headache: a pressing band across the forehead, often with tight neck and shoulder muscles, linked to stress, poor sleep and posture
• migraine: often felt at the front or temple, throbbing, with nausea and light sensitivity
• sinusitis: pressure over the forehead and cheeks with congestion and discolored discharge, worse bending forward
• eye strain: after prolonged screen use or uncorrected vision
• cluster headache: severe pain around one eye and forehead
• caffeine withdrawal, dehydration and hunger
• giant cell arteritis: temple pain and tenderness over 50
• acute glaucoma: frontal pain with a red eye and blurred vision, an emergency

Headaches that come and go with shooting pains

Brief, shooting or stabbing pains that come and go are often primary stabbing headache or occipital neuralgia (shooting pain from the back of the head over the scalp). Trigeminal neuralgia causes electric shocks in the face. These are usually benign, but new patterns or associated neurological symptoms need assessment.

Common triggers

• stress and anxiety
• poor or irregular sleep
• skipped meals and dehydration
• alcohol, especially red wine, and caffeine overuse or withdrawal
• hormonal changes, such as menstruation
• bright lights, loud noise and strong smells
• poor posture and neck tension
• overusing pain relievers

Diagnosis

Most headaches are diagnosed from a careful history:

• when and how the headache started, its location, character and duration
• associated symptoms, triggers and family history
• medicines and how often pain relievers are used

A headache diary recording dates, severity, triggers and treatments is very useful.

A doctor will examine the nervous system, eyes and blood pressure. Brain imaging (CT or MRI) is needed only when red flags are present or the pattern is atypical. For most recurrent headaches, scans are normal and not required.

Treatment

Acute treatment

• acetaminophen (paracetamol), ibuprofen, naproxen or aspirin for tension-type headaches and mild migraine, at the label dose. Do not give aspirin to children or teenagers
• triptans (such as sumatriptan) for moderate to severe migraine
• newer migraine drugs: gepants (ubrogepant, rimegepant) and lasmiditan
• anti-nausea medicines for migraine
• high-flow oxygen and injectable sumatriptan for cluster headaches

Limit acute painkillers to fewer than 10 to 15 days a month to avoid medication overuse headache.

Preventive treatment

Considered if headaches are frequent or disabling:

• migraine: beta-blockers, topiramate, amitriptyline, candesartan, CGRP monoclonal antibodies, gepants and Botox for chronic migraine
• tension-type: amitriptyline
• cluster: verapamil, and short-term steroids or nerve blocks

Non-drug approaches

• regular sleep, meals, hydration and exercise
• stress management, CBT, relaxation and biofeedback
• physical therapy for neck and posture problems
• limiting caffeine
• correcting vision problems

Frequently asked questions

What are the main types of headaches?

The main primary headaches are tension-type headache, migraine and cluster headache. Secondary headaches are caused by other conditions such as sinus infections, medication overuse, high blood pressure, infections, head injury or, rarely, bleeding or tumors in the brain.

What causes frontal headaches?

Frontal headaches are most often tension-type headaches or migraine. Other causes include sinusitis, eye strain, caffeine withdrawal, dehydration, cluster headache and, in people over 50, giant cell arteritis. A frontal headache with a red eye and blurred vision may be acute glaucoma.

When should I worry about a headache?

Seek emergency care for a sudden, severe headache, or a headache with fever and stiff neck, confusion, weakness, vision loss, a seizure or after a head injury. See a doctor for new headaches after 50, headaches that wake you, or a change in your usual pattern.

Why do I keep getting headaches?

Frequent headaches are often caused by migraine, tension-type headache or medication overuse from taking painkillers too often. Poor sleep, stress, skipped meals, dehydration and caffeine can contribute. A headache diary and a doctor's review can identify the pattern and treatment.

Why are headaches so bad after a lumbar puncture?

Spinal fluid can leak through the needle hole, lowering pressure around the brain. When you sit or stand, the brain sags slightly and pulls on sensitive structures, causing a headache that eases when you lie down. Most resolve within a week, and a blood patch can help severe cases.