Dr. Emese Orban
neurologist
Introduction
Headaches are among the most common and debilitating neurological conditions worldwide. The International Classification of Diseases defines headaches as painful conditions affecting the upper part of the head that can severely impair daily functioning and quality of life. (1)
Headaches can severely impact patients’ lives, leading to increased absenteeism from work and school, as well as substantial economic losses due to reduced productivity and healthcare costs (2, 3). The onset and progression of various types of headaches can be attributed to a biopsychosocial model, which includes biological (obesity, sleep disturbances), psychological (stress, psychiatric disorders), and social determinants (4, 5). A significant proportion of these factors can be modified, which may reduce the occurrence of headaches. Therefore, understanding the burden and trends of headaches is essential for public health planning, healthcare delivery, and research priorities. (6)
Warning signs
Most headaches are benign, caused by stress, dehydration, or fatigue. However, certain types may signal serious neurological conditions, and recognizing the warning signs associated with headaches can save lives (7). Specific symptoms that require urgent medical attention include:
- sudden, intense pain (“the worst headache of my life”)
- changes in familiar headache patterns (more frequent, more intense, or different from usual)
- headaches accompanied by fever, confusion, altered consciousness, weakness, numbness, or problems with vision, speech, or balance
- headache associated with a traumatic brain injury
- new headaches after age 50
- headache accompanied by persistent vomiting, especially in the morning
- headaches in people with known medical conditions: cancer, HIV/immunosuppression, bleeding disorders
- pain triggered by physical exertion, coughing, sneezing, or sexual intercourse
Recognizing warning signs helps distinguish harmless pain from dangerous conditions. Any of these findings in the context of a headache should prompt a neurological evaluation and further testing.
Types of headaches
Certain types of headaches are more commonly encountered in primary care. These include migraine, which occurs episodically in 12–16% of the general population, predominantly among women. It is characterized by attacks of moderate or severe headache, often unilateral in location, with a throbbing quality, lasting between 4 and 72 hours, frequently associated with nausea and/or vomiting, and is aggravated by routine physical activity. Another major subtype is migraine with aura, which affects 10% of the population and is characterized by symptoms such as visual disturbances, unilateral paresthesias, or dysphasia that develop gradually and resolve within approximately 60 minutes.
The second most common type of headache encountered in clinical practice is the tension-type headache, which lasts from a few hours to several days, is usually generalized, and is typically described as a feeling of pressure or tightness, like a band wrapped tightly around the head. This type of headache occurs episodically and affects over 80% of the population.
Cluster headaches are easy to recognize; they primarily affect men and are strictly one-sided, occurring around the eye.
It is short-lived (15–18 minutes), occurs frequently, and is characterized by the presence of autonomic symptoms such as tearing, runny nose, nasal congestion, and ptosis (drooping eyelid). This type of headache causes marked agitation; the patient is unable to stay in bed and feels a constant need to move around.
A common type of chronic headache is medication-overuse headache, which occurs almost daily and is associated with excessive use of pain relievers. This type of headache is most often more severe in the morning upon waking.
Triggering factors
Beyond the type of pain itself, triggering factors play an important role. Among the most common are stress, lack of sleep or an irregular sleep schedule, severe fatigue, and dehydration. Diet can also influence the onset of headaches: skipping meals, alcohol consumption, excessive caffeine intake, or, conversely, abruptly stopping coffee consumption can trigger painful episodes. Some people are sensitive to certain foods, such as chocolate, aged cheeses, or related products.
Common environmental factors that contribute to headaches include bright light, loud noise, strong odors, or changes in the weather. For some people, headaches can be influenced by hormonal fluctuations, such as during menstruation. Postural factors should not be overlooked either; for example, prolonged sitting at a desk in front of a computer can contribute to the onset of pain.
Common mistakes in managing headaches
Many patients try to manage the problem on their own, which can lead to complications: frequent use of pain relievers without a doctor’s recommendation, delaying a specialist consultation, and ignoring recurring patterns of pain. In some cases, overuse of medication can even make the headache worse.
Treatment depends on the type and cause of the headache. It may include: lifestyle changes (sleep, hydration, stress reduction), medication tailored to each patient, and further testing when necessary.
Conclusions
In conclusion, headache is one of the most common complaints encountered in medical practice, with a wide range of causes, from benign primary forms to potentially serious secondary causes. Correctly identifying the type of headache is essential for appropriate treatment.
In this context, the neurological examination plays a central role in the evaluation of patients with headache. It allows for the differentiation between primary and secondary forms by identifying any focal neurological signs, changes in mental status, or other clinical clues suggestive of an underlying condition. A normal neurological examination, in the absence of red flags, most often supports a benign diagnosis, reducing the need for costly or invasive additional investigations.
On the other hand, the presence of abnormalities on neurological examination necessitates further investigation, sometimes on an emergency basis, to rule out serious conditions such as intracerebral hemorrhages, space-occupying lesions, or central nervous system infections. Thus, the clinical examination remains a first-line tool, indispensable in the triage and management of patients with headache.
Therefore, careful integration of the patient’s medical history with the results of the neurological examination significantly contributes to establishing an accurate diagnosis, guiding diagnostic tests, and initiating appropriate treatment, thereby having a direct impact on the patient’s prognosis and quality of life.
References
- World Health Organization.Atlas of headache disorders and resources in the world 2011.World Health Organization, 2011.
- Malmberg-Ceder, Kirsi, et al. "The impact of self-reported recurrent headache on absenteeism and presenteeism at work among Finnish municipal female employees."Journal of Pain Research (2020) 2135-2142.
- Rousseau-Salvador, Celine, et al. "Anxiety, depression and school absenteeism in youth with chronic or episodic headache."Pain Research and Management19.5 (2014): 235-240.
- Smitherman, Todd A., Morris Maizels and Donald B. Penzien. "Headache chronification: screening and behavioral management of comorbid depressive and anxiety disorders."Headache: The Journal of Head and Face Pain 48.1 (2008): 45-50.
- Nicholson, Robert, and Marcelo Bigal. "Screening and behavioral management: obesity and weight management."Headache: The Journal of Head and Face Pain48.1 (2008): 51-57.
- Shen L., Li H, Wang K, Guo T and Ye J (2025) Global, regional, and national burden of headache disorders, 1990-2021, and projections to 2050: a comprehensive analysis of the global burden of disease study 2021. Front. Neurol. 16:1674946.
- Orban E., R. S. Sipos - Headache - Symptom, Sign or Disease.Medic.ro. Journal of Continuing Medical Education. Year XVII no. 134 (2/2020): 44-46.
- Prof. Dr. Băjenaru O. - Guidelines for Diagnosis and Treatment in Neurology. Med. Amaltea Publishing, Bucharest, 2005, 5:143-147.