By William Jantsch MD

What can I do about this headache?

Headaches are a common affliction among humans, with almost 90% of people experiencing this during their lifetimes. Happily, most headaches are simply a benign nuisance, commonly the result of tension of the muscles, ligaments, and nerves of the scalp. However, headache can also be a symptom of a serious underlying disorder. These “serious headaches” are relatively rare, but it is the doctor’s duty to try to make sure that the patient he or she is treating does not have a potentially crippling or lethal condition. 
What options, then, are open to someone who is experiencing a headache? What follows is some background information, and perhaps some general guiding principles.
Most mild headaches, while uncomfortable, will resolve in time and not leave any health-related consequence. “Tension headaches”, often felt by people under stress, tension, or eye strain usually come and go gradually, are not associated with “sick” symptoms (such as nausea, vomiting, dizziness, light sensitivity), and will usually resolve with over the counter analgesics such as acetaminophen or ibuprofen. People with tension headaches usually have a long history of episodic headaches of a similar nature.

A “migraine” is a clinical syndrome, not just a headache. Migraine sufferers experience periodic headaches that may be preceded by visual or neurological symptoms (such as flashing lights in one eye, focal weakness or numbness in the arms, face, or legs), followed by a severe headache on one side of the head, associated with light sensitivity, nausea, and vomiting. 

“Serious” headaches are those that signal the presence of an underlying disorder that would require urgent or emergent treatment to minimize death or disability. Examples of such conditions would include:
- Intracranial hemorrhage (bleeding), due to:
o Aneurysm of a brain artery (enlargement with possible rupture of the blood vessel)
o Intracerebral hemorrhage (bleeding into the brain)
o Subdural or epidural hemorrhage (usually seen after a serious head injury)
- Stroke
- Meningitis
- Brain tumor
- Vasculitis (blood vessel inflammation, such as seen in Lupus)

Symptoms that could indicate the presence of one of these life threatening conditions would include:
- Very sudden onset of very severe headache (doctors call this a “thunderclap” headache), sometimes described by patients as “the worst headache I have ever had”
- Impairment of level of consciousness
- Fever
- Uncontrollable vomiting
- Impairment of vision, weakness or numbness anywhere on the body

Notice that migraine headaches can be severe and be associated with “sick” feelings; one of the first questions a doctor will ask in evaluating such a headache is “have you ever had a similar headache in the past?" A presumptive diagnosis of “benign" headache can be made just on the basis of documenting a previous pattern of similar headaches, and no further testing may be needed prior to instituting treatment.
If you have a previous history of recurrent headaches, and happen to be suffering from yet another episode with pain that is similar in character and location, then it is probably not a “serious” headache even if the pain is severe. On the other hand, if you are the kind of person who never gets headaches, and there is a sudden onset of severe pain along with any other symptom, then it would be prudent to go a hospital emergency department in order to get immediate testing and treatment. Appropriate evaluation of a “new, severe, sick” headache cannot be performed in a doctor’s office or an urgent care center.

If there is any question about where to go for evaluation and treatment of a headache, you have several options:
- Call your primary doctor for advice.
- Try a telehealth consultation, such as with an Ns1ghter provider. Ns1ghter has the advantages of being free and readily available, and can quickly give you an idea of how best to get an appropriate evaluation. Some of the national telehealth services offer the additional benefit of prescribing medication, but they may not be as thorough with follow-up evaluations as your primary doctor might.
Treatment options for benign headaches will be the subject of another blog post.

Thanks for reading, and I hope that this advice has helped.