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Making sense of Headaches

Updated: Sep 12, 2019

Headache is the third most common chronic pain condition in the western world, and it exacts an enormous healthcare burden.

Despite its wide prevalence, there is a great deal of confusion as to both the diagnosis and management of headaches. In this series we are going to try to make some sense of the headache conundrum – what type of headache you may have, is it a sign of something more sinister going on, if not what is causing my head pain, and what can I do about it.


First let’s look at headache diagnosis.

The International Headache Society has classified over 100 subtypes of headache – in headache inducing detail!

It is helpful to understand the basics of these classifications though.

The first step in headache diagnosis is to understand if your headache is a primary or a secondary headache.


Primary headache is one that is NOT related to a specific underlying pathology – in other words the headache sufferer appears to have a genetic predisposition to headache because of alterations in their neurophysiology. The big ones here are Tension Type Headaches, and Migraine, and to a lesser extent Cluster Headaches.


Secondary headache is one that can be attributed to another underlying pathological cause. These can range from the extremely serious (tumours, stroke, meningitis) to more benign causes such as sinusitis or referred pain from a neck problem.


So, what are the most prevalent forms of headache? And how do we differentiate between them?

More and more we are recognising that the boundaries between headache types are blurred and most headache sufferers exist along a spectrum of varying symptoms, however it is helpful to understand the key features and prevalence of the major types.

The most common headache type is Tension Type Headache – 38% of all headaches. Classically, this is a mild to moderate headache with pressing or tightening nature that generally effects both sides, it is generally not made worse with exertion and isn’t associated with nausea or vomiting, though you may feel a degree of sound or light sensitivity.


Migraine is the next most common headache type – 10%. Migraine can be with or without aura symptoms such as visual disturbances, pins and needles or speech difficulties. Importantly, these aura symptoms are all fully reversible within 1 hour. Migraines are generally moderate to severe and can last anywhere between 4 and 72 hours and is generally one sided with a pulsing or throbbing nature. Importantly, migraines are associated with nausea and vomiting, light and sound sensitivity and are worsened by exertion and impair daily activities.


Cluster headaches are actually quite uncommon – less than 1% of primary headache. Cluster headaches are a severe one sided headache in or around the eye or temple region lasting 15 minutes up to 3 hours. These occur once every 24 hours for 6 – 12 weeks at a time, and are often return at the same time of year or season. They often have associated autonomic symptoms such as a watery eye or nose, facial sweating, pupil constriction, and drooping or swollen eyelid.


Cervicogenic headache - 4%. A true cervicogenic headache is actually a secondary headache as it is referred pain from a structure in the neck, such as muscle or joint. The pain will start in the neck, and project to the top or front of the head. The pain is usually one sided and may also spread to the shoulder or arm on the same side. The headache symptom will be aggravated by certain neck movements or sustained neck postures. It is important to remember that a true cervicogenic headache is one in which the patient would not have any headache whatsoever without a neck problem. In reality, both tension type and migraine headaches are associated with neck pain, but the neck pain is more likely a symptom of the headache rather than the sole cause.