Recurrent Headaches

RECURRENT HEADACHES completely disappear for at least a week, often months or years, only to return again.  Rarely are they due to anything dangerous, since those conditions don’t go away on their own. However, we must always be clear the recurrence feels like previous episodes, & isn’t a different headache. A new and different headache could be anything.

Causes of Recurrent Headaches

zzzzzzzzzzDangerouszzzzNot Dangerous (usually not)
** Pheochromocytoma
** Depressed AND Suicidal
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** 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

First: Consider the one dangerous possibility (very rare):

Headache PLUS Sweating PLUS Tachycardia (rapid heart rate) — may be Pheochromocytoma

  • Blood pressure very high during episode (normal blood pressure at the time rules it out)
  • Other symptoms may be tremor and palpitations
  • Eye exam of retina may show unusual signs of high blood pressure
  • Diagnosis: blood test, or better a 24-hour urine collection, for certain adrenal hormones.  CT Scan if the blood or urine tests are high (need to be extremely high, not just a little elevated above normal values)

Depressed AND Suicidal — we establish rapport by considering other causes first (see below at end)

Second:  Consider common causes related to Nose or Neck

  • Major nasal symptoms like congestion, runny nose, sneezing, with headache mainly in front of head.  May be Allergic Rhinitis (Hay Fever), or Sinusitis; see topic Nasal Congestion to distinguish.
  • Pain with turning or bending head; neck muscles may be tender when pressed on: likely a Neck Sprain or Strain.

Third:  Consider Unique Types of Headache

**  Migraine Headache

  • Usually lasts 4 – 72 hours (“atypical migraines” may last longer)
  • Requires both (a) AND (b)
    • Two of the following four characteristics: 1) pulsating or throbbing, 2) one side of head only, 3) moderate or severe, 4) made worse by normal activity
    • At least one of the following two characteristics: 1) nausea / vomiting, or 2) photophobia plus phonophobia (both light & noise make the discomfort much worse).
  • May have prodrome 1-2 days before the headache: mood changes, maybe yawning.
  • Some people have an aura: various visual or skin sensation, lasting 5-60 minutes, immediately before headache begins.
  • Treatment Trials help confirm diagnosis, see text (there is no diagnostic test)

**  Cluster Headaches: several times / day, almost daily for weeks, go away, return

  • Headache 15 min. to 3 hrs., 1 to 8 times per day
  • Almost daily for month or more, gone at least a month, return
  • Severe, one-sided near eye or temple, with funny symptoms on same side:
    • red eye, tearing, eyelid swells or droops, pupil constricts
    • Runny nose / congestion (one side)
    • Face / forehead sweats (one side)
    • Restless or irritated

None of Above?  Then probably the most common headache of all

**  Tension Headache

  • Usually both sides of head (or all over)
  • Usually pressure sensation (not throbbing)
  • Often related to, or worsened by, Stress (but can occur without it)

But Don’t Forget about the less common headaches

**  Medication Overuse Headache

  • Caused by any common pain medicine (usually narcotics, butalbital, acetaminophen, etc.)
  • Taking a single pain med 10 days per month, or a mixture 15 days
  • Diagnosis:  stop all pain medicines, begin migraine prevention meds

**  Medications / Drugs / Toxins / Irritants  —  We’d suspect if headache occursโ€ฆ

  • โ€ฆwhen taking a certain medication or street drug
  • โ€ฆwhen re-entering a specific environment

**  Special Headaches  (we suspect only after a pattern has been set)

  • “Cough Headache” — begins after coughing
  • “Post-Coital Headache” — occurs during sex, or right afterwards
  • “Chinese Restaurant Headache” — from monosodium glutamate
  • “Hot Dog Headache” — from foods preserved with nitrites

Finally — Be sure patient isn’t Depressed AND Suicidal

Any Depression or Anxiety can cause a headache, as can any Mental Stress or Physical Discomfort. But whenever we diagnose depression, we always ask, “Is your depression so strong that you sometimes think of killing yourself?

  • If so, we ask simply if they have a plan, have the means, and evaluate risk from there

See also Recurrent Headaches – Full Text for more in-depth discussion & explanations.

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