RECURRENT HEADACHES are ones which completely disappear, only to return again. We have to be clear that today’s recurrence feels pretty much the same as previous episodes, because the chronic migraine sufferer is also allowed to happen to have a fatal subarachnoid hemorrhage or get meningitis, just like anyone else might. See also “Recurrent Headaches” for the clinician’s condensed thought process when face-to-face with a patient.
Knowing the possibilities is, as always, key to Diagnosis:
Causes of Recurrent Headaches
| zzzzzzzzzzDangerous | zzzzNot Dangerous (usually not) |
|---|---|
| ** Pheochromocytoma ** Depressed AND Suicidal xx xx xx xx xx xx xx | ** Allergic Rhinitis (hay fever) / Sinusitis ** Neck Sprain or Strain ** Migraine Headache ** Cluster Headache ** Tension Headache ** Medication Overuse Headache ** Medications / Drugs / Toxins / Irritants ** Special Headaches ** Depression / Anxiety / Any Discomfort |
Patients with recurrent headaches aren’t usually worried about life-threatening illness, because they know that whatever condition is causing pain didn’t do them in last time. However…
Life-Threatening Causes of Recurrent Headaches
** Pheochromocytoma — A tumor of the adrenal gland, which sits atop the kidney (separate from it), & makes a number of hormones including adrenalin. Known in medical jargon as a “Pheo” for short, it’s “benign” in the sense of not cancerous. But imagine a tumor pouring out uncontrolled amounts of adrenalin every so often — that’s not so benign at all in common-speak. Sufferers can die from effects of extreme hypertension. Don’t fret too much; it’s pretty rare (≤1 per 100,000 population).
Half of patients with Pheos have high blood pressure all the time; the others have intermittent rises accompanied by headache, generalized sweating, palpitations, tremors, or turning pale. Anyone with recurrences of such symptoms needs tests to rule it out.
Diagnosis is made by a 24-hour urine collection to test for certain adrenal gland hormones. Sometimes a simple blood test can make do instead. Results have to be extremely high; small elevations above normal don’t count. If these tests are abnormal, next step is a CT Scan of the Adrenal Glands to look for a tumor.
Of course, at the time of the first appointment, the episode may be over and blood pressure may be completely normal. If a medical provider seems doubtful about symptoms, patients should make 2 requests:
1. They examine the arteries & veins in your retina (the back of the eyes), where they might be able to notice damage from repetitive blood pressure surges (a rare finding, but one which would convince them fast)
2. They let you drop in without an appointment the next time you have an apparent attack; if your blood pressure is normal then, you don’t have a Pheo.
** Depression AND Suicidal — People who are depressed often have headaches. Depression is common, but in extreme cases, it can lead to suicide. So whenever we think a person may be depressed, we gently question and explore their mood. And if indeed they acknowledge their depression, we follow up by asking, “Does your depression ever get so severe that you ever think about killing yourself?”
We wouldn’t address this until the end of our visit, having thought through all the other possible causes first. And obviously it wouldn’t make any sense to inquire about suicidality until establishing that the patient is, in fact, depressed.
We never worry about “planting the idea,” because that’s impossible. Nobody would ever say, “Oh, I never thought about that; maybe I should.” Quite the contrary, anyone who is the least bit suicidal can’t escape the torment. They’re usually relieved we’ve asked.
Almost half of people who attempt suicide interact with healthcare professionals the week before, in one way or another. And it’s not for depression. Maybe they seek care for a runny nose, or a headache…
See also Depression.
Common Causes of Recurrent Headaches
Onward to the common causes of recurrent headaches, beginning with two conditions addressed under “Acute Headache” (& repeated here).
** Allergic Rhinitis / Sinusitis — If there are significant nasal symptoms like congestion, runny nose, sneezing, or facial pressure, & the headache is mostly felt in the front of the head, either Allergic Rhinitis or Sinusitis is likely the cause. Allergic Rhinitis is the medical term for what people call “allergies” or “hay fever.” It’s much more common than Sinusitis (a bacterial infection). When a patient says their “sinuses are acting up,” it’s almost always allergies.
See our topic Nasal Congestion for ways to distinguish between these conditions. But at any rate, if nasal symptoms are present, especially if the headache is mainly felt in the face or forehead, we’ve identified its likely cause.
** Neck Strain or Sprain — Any trauma to the neck can cause a headache. Sometimes it’s obvious, like getting rear-ended in a car. But the event may be trivial, like a sudden twist, or having to keep the neck in an unnatural position for a time. In such cases, the pain may begin a day or two later (when muscles swell inside), & the person doesn’t even recall what happened.
We suspect the neck as the source of “headache” if pain is increased by bending or rotating it. We also palpate the muscles & bones for tenderness, & have the patient move their neck in different directions, then do it again against resistance (we push against it). If any of that hurts, we have our diagnosis.
Now, for the “primary headache disorders,” termed as such because they’re not due to anything else.
** Migraines — Above all, migraines are cyclical headaches. They come, go, and recur. An attack typically lasts more than four, & less than 72, hours. Of course, there are also what are called “Atypical Migraines,” which act differently (last longer, have variable symptoms, etc.), but are relieved by normal migraine treatment.
The International Headache Society (IHS) has its criteria to diagnose Migraines:
- Two of the following four characteristics: 1) pulsating, 2) unilateral (one side of head only), 3) moderate or severe intensity, 4) exacerbated by normal activity; and also
- At least one of the following two characteristics: 1) nausea / vomiting, or 2) photophobia plus phonophobia [both light & sounds make the discomfort much worse].
Up to 60% of migraine sufferers experience a “prodrome” 1-2 days before the headache, consisting of mood changes, perhaps increased yawning. Up to 25% have an aura, a variety of visual or other strange sensations, lasting 5-60 minutes immediately before headache onset.
Head CT scans & MRIs aren’t necessary unless your examiner finds actual neurological deficits (possible with a simple migraine, but quite unusual). The IHS requires five episodes before a migraine diagnosis can be made, but this is mainly for research purposes. If a patient has had at least 2 episodes (proving recurrence), a “treatment trial” may help.
“Treatment Trial” is really a diagnostic trial, of therapy. If a medicine helps, that’s probably what you have. But of course, placebo helps too, so clinicians who order treatment trials should maintain a certain degree of healthy intellectual skepticism.
For migraines, there are 2 possible treatments (aside from simple pain medications). See our topic Migraines for mention of these. Treatment Trials should aim for maximum dose of medication, building up to it as tolerated. If you just try a low dose, and it doesn’t work, you’ll never know if more actually might have helped.
** Cluster Headaches — This diagnosis tests a clinician’s skill at defining the time frame of a symptom. Cluster headaches:
- Occur daily, or every other day, usually for 6-12 weeks [range: anywhere from 1 week to 1 year], then disappear for at least a month, then recur.
- Each attack lasts 15 minutes to 3 hours. They may strike 1 to 8 times a day.
- The headache is severe, one-sided, felt around the eye or temple.
- There’s at least one other finding on the same side as the headache:
- red eye or tearing, eyelid swelling, pupil constriction, or droopy eyelid
- runny nose [nostril] or congestion
- one-sided forehead or facial sweating
- restlessness or agitation [this would be in general]
If Cluster Headache is diagnosed, an MRI is usually recommended, because a disproportionate number of patients with typical signs & symptoms of cluster headache happen to have brain abnormalities, suggesting that some of these may be related.
Cluster headaches are much less common than migraines. There’s about a 1/1,000 lifetime chance; men may outnumber women 4:1. A number of other variations mimic clusters, with shorter duration and more frequent bursts. Since treatment may vary, we’d refer to a headache specialist.
If we diagnose cluster headaches, we need inquire about coping mechanisms. There have been suicides among cluster headache sufferers.
** Tension Headache — This is the most common of all headaches, the one with greatest impact on life, the one least studied, & the most nondescript — tension headache is a “diagnosis of exclusion.” In other words, nothing else seems to fit. The pain is likely felt on both sides of the head (often all over), is not severe, usually described as “pressure,” with no symptoms to suggest migraine or cluster, much less anything dangerous. It can be brief or last for weeks.
What else can I say?
Finally, there are other categories of Recurrent Headaches:
** Medication Overuse Headache — This commonly mimics Tension Headache. A person complains of a headache, takes over-the-counter medication or gets a prescription, uses them continuously. When they stop (or run out), a rebound headache occurs. So they seek refills for more medication. Vicious cycle.
The main drugs responsible seem to be narcotics like codeine, hydrocodone (Norco®,Vicodin®) or oxycodone (Percocet®, Oxycontin®), combination products with the barbiturate butalbital (e.g. Fiorinal®), and acetaminophen (Tylenol®). Those with aspirin + acetaminophen + caffeine have also been implicated, triptans too, and even NSAIDs (ibuprofen, naproxen, etc.).
We consider this diagnosis if a single headache medication is taken over 10 days per month, or if various meds are mixed for over 15 days. To diagnose it, we discontinue all possible offending medications, and begin a migraine-prophylaxis regimen (see Migraines). It’s often hard to convince people that their beloved pain medicine is working against them.
** Medications / Drugs / Toxins / Irritants — Almost any medicine might be able to cause a headache. We diagnose this if there’s no other cause for a patient’s headache, and they had recently begun taking something new. Then we’d look it up in our resources for medication side effects, and see if the medication had ever been reported to be associated with a headache (but we’re careful with our conclusions; please see Beware Reading About Medication Side Effects).
The same goes for herbs, supplements, and street drugs. In terms of the latter, not only might the drug cause headache, but withdrawing from it might also. Same holds true for medicines & any substance.
If a person gets a headache repeatedly in a certain environment, we’d suspect an environmental cause. These can range from life-threatening (like carbon monoxide), to simply annoying (like ammonia). Diagnosis takes detective work.
** Special Headaches — Certain stimuli may cause brief headaches. They include:
- “Ice-Cream Headache” (“brain freeze”), when enough cold hits the roof of the mouth fast enough.
- “Cough Headache” occurs after coughing.
- “Post-Coital Headache” occurs during or right after sex; it can be emotionally traumatic.
- “Chinese Restaurant Headache” from eating products with monosodium glutamate.
- “Hot-Dog Headache” from foods with nitrites.
These headaches should only be diagnosed after numerous occurrences have set a pattern, not with the first episode. Because of the intense straining, a Subarachnoid Hemorrhage from a brain aneurysm leak can also occur during sex.
** Depression / Anxiety / Any Discomfort — Any mental or physical stress can cause a headache. If your back pain acts up from time to time, the annoyance and irritation can be enough to cause a headache. Sometimes the latter can overtake the former as the most bothersome symptom, leading a patient to seek medical care. Insight into this alone may relieve the headache (though maybe not the back pain).
As noted above, anytime we diagnose a mood disorder like Depression, we inquire into the worst case possibility, danger to oneself (suicidality) or even danger to others (violence or homicidality). If present, we obviously address it.
See also Recurrent Headaches for the clinician’s condensed thought-process when face-to-face with a patient.