When a headache is a pain! About primary and secondary headaches

When a headache is a pain! About primary and secondary headaches

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065



Headaches are a very common reason that patients consult a neurologist like me.  The intensity of the headache, its character and duration are some of the factors which determine if and when patients seek medical attention. So in this post I shall go over the different types of headaches and list their main differentiating features.

Broadly speaking we can divide headaches into primary and secondary headaches. Primary headaches are those headaches for which there is no structural/ secondary cause.  For example a migraine headache is an example of a primary headache. The migraine may be severe and frequently disabling but if you scan (CT or MRI) the patient’s brain no underlying structural lesion like a tumor is found. Secondary headaches as the name implies are secondary to a another cause. For example headache due to a large brain tumor or headache due to an infection (meningitis) represent secondary headaches.

Types of primary headaches:

1)      Migraine: common migraine and classical migraine

2)      Tension type headache

3)      Cluster headache

Types of secondary headaches:

1)      Headache secondary to a brain tumor or other masses (space occupying lesions) in the brain

2)      Headache secondary to an infectious and inflammatory process in the brain (example headache associated with meningitis)

Headaches can be a cause of concern and distress. Patients frequently worry that may have a brain tumor. So let us go over some of the signs and symptoms which suggest that the headache is due to a secondary cause . These are the signs and symptoms which should make you seek urgent medical attention:

  1. Sudden onset of severe headache. When asked patients rate their headache as the “worse headache of their lives”. I shall be concerned if I encounter such as patient in the ER, more so if the patient tells me that they have never had a  headache in their life before. When accompanied with other signs such as nuchal (neck) rigidity and depressed sensorium (level of alertness), the question of subarachnoid hemorrhage (SAH) comes to mind. A common cause of non-traumatic SAH is the rupture of an aneurysm or arteriovenous malformation (AVH) in the brain. SAH is associated with high morbidity and mortality especially if the patient presents to medical attention late.

Caveat: Not all “worse headaches of my life” are due to SAH due to rupture of an intracranial aneurysm. Many times (especially if there is a past history of migraine headaches) these patients are suffering from a particularly debilitating/ severe attack of migraine. Thunderclap/ explosive headaches have also been reported at the time of coitus. They are referred to as post coital or orgasmic headache.

  1. Headaches in extreme of ages:  headaches which occur in the extreme of ages (such as in a young child or after middle age especially if there is no past history of headaches) deserve a more closer look. Signs such as neck stiffness or depressed level of sensorium may be masked or difficult to elicit in these age groups. As a neurologist my threshold of investigating these patients with tests such as MRI of the brain and more invasive tests such as spinal tap (lumbar puncture) is lower.

Caveat: small children frequently cannot express headache (meaning they cannot tell you that they are bothered by headache).  Primary headaches such as migraine may be missed in children as a result. The child may be agitated and parents may think he is acting up. So a high index of suspicion has to maintained by the physician to timely identify migraines in small children. Also it is well known that migraine is not “typical” in the pediatric age group. Various migraine variants have been identified in children such as abdominal migraine (the child complains of episodic abdominal pain), cyclical vomiting and so forth.

  1. Onset of headache in middle age (especially if there is no prior history of headaches): when a middle aged patient comes to me and says he is bothered by headaches for the past 3-4 months, never had headaches when he was in his teens, I pay close attention to him. A thorough neurological examination shall frequently tell me if there is anything “brewing” inside the brain aka does he have a mass lesion/ tumor? As a neurologist I have several tools to help me in this endeavor. I can look for signs of asymmetry: weakness/ numbness on one side of the body, problems with coordination on one side of the body, is the gait steady, are the reflexes symmetrical and so forth. I can further look into his eyes with an ophthalmoscope to see if there is increased pressure inside the brain (remember the eyes are the window into the brain).  Based on my exam, I may or may not order a MRI scan or CT scan to confirm my suspicion.
  2. Headaches associated with fever: are always a cause of concern. Various disease processes such as meningitis (bacterial, viral or fungal), brain abscesses and so forth come into the differential. Patients are admitted into the hospital and further management depends upon the underlying etiology.
  3. Recent onset of headache in an immunocompromised patient: recent onset of headache in a patient who is immunocompromised (example a HIV positive patient or a patient who is receiving chemotherapy for cancer) always warrant a thorough work-up. Such patients are frequently found to have a secondary cause for their headaches. So again my threshold for imaging such patients is low.  My threshold for doing a spinal tap in these patients is also low (provided I am confident that the pressure in the brain is normal).
  4. Headache/ temporal pain  in a patient past 65: temporal arteritis (Giant cell arteritis) is a disease entity which is seen in the elderly and is due to inflammation of the temporal arteries. Patients may not complain of headache per-se. When you examine them you find they have tenderness over the temporal arteries and the artery may feel beaded and thickened.  It is imperative that temporal arteritis be identified in a timely fashion and treated otherwise the patient may suffer loss of vision.

In the next post I shall talk about the primary headaches.



 We have all suffered from a headache at some point in our life. Thus headache is among the most common neurological disorder seen in the out patient neurological clinic. I shall discuss headaches under 2 headings:

1) Primary headaches such as migraines (both common and classical), tension type headache and episodic cluster headaches.

2) Secondary headaches such as headaches associated with brain tumors, temporal arteritis (giant cell arteritis), headaches associated with subarachnoid hemorrhage and meningitis.


Primary Headaches:


1) Migraine: migraine is the most common primary headache disorder. It commonly starts in adolescense and affects women more than men. Migraine is of 2 types:

a) Common Migraine: this is the common variety of migraine in which the headache is not accompanied or preceeded by any aura. Patients usually have complaint of episodic headaches which have a typical character. Headaches are typically unilateral (though the headache may shift from side to side in different episodes) and are accompanied by nausea and vomiting. Patients may complain of dizziness and also usually are sensitive to bright lights and loud sounds at the time of their headache. Sensitivity to loud sounds is called phonophobia and that to bright lights is referred to as photophobia. During an acute attack patients usually feel and look sick and prefer to lie in a quiet dark room. Shaking the head makes the headache worse. Sleep naturally aborts an attack with patients waking up headache free.

b) Classical Migraine: this is migraine with aura. Patients experience an aura at the onset of the headache. The aura is usually visual and patients may complain of seeing bright flashing lights or spots/ halos in front of their eyes (referred to as scintillation scotoma or fortification spectra). Many different types of visual auras have been described, you can see the pictures of some of them by googling scintillation scotoma and looking under images.


2) Cluster headache: this is another type of primary headache disorder which predominantly affects young to middle aged men. Episodic cluster headache is characterized by episodes of intense unilateral headache usually around the peri-orbital area (pain is centered around the eye) associated with nasal congestion, lacrimation (tearing from the eyes) and nasal stuffiness. The headache usually awakens the patient at the same time every day and may be so intensely uncomfortable that some patients have been known to commit sucide. These episodes of daily headache may last for a few weeks and then abate spontaneously only to recur at a later date.


3) Tension type headache: this is a rather common type of primary headache disorder. More commonly seen in women, tension type headache is characterized by holocranial headache (the whole head hurts) or the patient may complain of tightness or a vise like sensation around the head (especially the nape of the neck).


A point to remember is that patients may have 2 or more types of headaches. For example a person suffering from migraine may also admit to having tension type headaches.


Pathophysiology of Migraines: Let us now discuss what causes migraines. The brain itself is insensitive to pain. Let me give a rather crude but effective example. If you take a knife and drive it through the brain, you shall feel no pain. The pain sensitive structures in the brain include the blood vessels which course through the brain, the venous sinuses (think of them as large reservoirs where the venous blood in the brain drains to) and the meninges. The meninges or the covering of the brain are richly supplied by nerves and hence are very sensitive to pain. Thus when one has inflammation of the meninges (condition referred to as meningitis), one has pain in the nape of the neck and headache.

There are many theories to explain the pathophysiology of migraine headaches, the one most accepted is referred to as the trigeminovascular hypothesis. According to this hypothesis, the blood vessels in the brain are innervated by branches of the trigeminal nerve. During a migraine attack, initially the blood vessels constrict (go into a spasm) and then dilate. That is time the patient complains of a throbbing headache, characteristic of a migraine. The pain is referred to the distribution of the trigeminal nerve (this nerve supplies the skin of the face) hence the complaint of pain in the temple and around the eyes. Hence migraine is rightfully thought to be a vascular condition.


The diagnosis of migraine is clinical (that means your doctor shall be able to make the diagnosis without ordering major tests). If there are elements in the history which are atypical for migraine then your doctor may order an imaging study such as an MRI scan of the brain. Usually this is done when there is a suspicion of a brain tumor.

Other atypical signs include:

1) weakness or numbness on one side of the body.

2) new onset headache in the middle aged or elderly.

3) headache associated with projectile vomiting (remember migraine too can be associated with nausea and vomiting).

4) headache which first presented with a seizure.


Once the diagnosis of migraine is secured then the question of treatment arises. There are a couple of aspects in the treatment of migraine which demand attention. The first is the treatment of an acute attack (you are suffering from an acute migraine headache, how to abort the attack and relieve the pain? What medication is the most effective? What if the medicine does not abort the headache attack?).

The second is the prophylatic treatment of migraine (treatment initiated so that you never have the attack in the first place).

There are different medications used to treat the acute attack of migraine and those for prophylatic therapy. I shall discuss them one by one.


Treatment of acute migraine attack: 

An acute attack of migraine can be debilitating. Effective treatment which quickly aborts the headache is the need of the hour. Any of the common pain-killers like aspirin, acetaminophen (tylenol), ibuprofen (motrin) is effective in the treatment of an acute migraine attack. The secret for the drug to be effective is that they should be taken right at the onset of the headache. Let me explain, you feel the migraine starting-a dull aching around the eye, the typical aura–if you take the tablet right now then it shall abort your headache. But if you decide to wait and the migraine attack evolves further into a classical unilateral throbbing headache with sensitivity to light and loud sounds, it is more than likely that either the pain killer shall not work or for it to work you shall have to take more than usual amount of the medication (more pills to break the attack). Also remember that most patients during a migraine attack feel nauseous and some may even throw up so it may be hard to keep the pill down.


Now we have more effective and migraine specific medications available. These medications which are commonly referred to as TRIPTANS include medications by the name of sumatriptan  (brand name Imitrex),  rizatiptan  (Maxalt), naratriptan (Amerge, Naramig), zolmitriptan (Zomig), eletriptan  (Relpax), almotriptan(Axert, Almogran), and frovatriptan (Frova, Migard). The triptans are 5HT 1D and 1B receptor agonists (meaning that they act on the serotonin receptors in the brain to exert their anti-migraine effects).  They are available in the tablet form to be taken orally (by the mouth). Some like sumatriptan can also be administered via the sub-cutaneous route (under the skin) or via the nostril as a spray. This is specially advantageous when the patient is having nausea and is throwing up. Your doctor may prescribe you a triptan. The various triptans differ from one another in their speed of action, side-effects and their efficacy. So if you do not have a positive response to one triptan, it is still worthwhile trying out another.


Another medication effective in the treatment of an acute migraine attack is DHE or dihydroergotamine. DHE is usually given intravenously (via a vein) but as compared to the triptans it has more side-effects and hence is not the first choice to treat an acute migraine attack. You may be given this medication if you land up in the emergency room with a bad attack of migraine that has not responded to the conventional pain-killers and triptans.


Other medications which are also effective in treating an acute attack of migraine include the opioids (morphine and codeine containing drugs). We as doctors avoid using these drugs because of their significant addictive potential. Patients may get addicted to their use and then start abusing the drugs.


Prophylatic therapy for migraine attacks: The idea behind migraine prophylaxis is to use a medication which prevents the migraine headache from coming on in the first place. If you can prevent an attack of headache from happening then you do not need to treat it. Makes sense you would say!!!

There are many different classes of drugs which have demonstrated efficacy in migraine prophylaxis. Let us discuss some of them. Some of the commonly used drugs for migraine prophylaxis are those that belong to a class called beta blockers. Drugs included under this class  commonly used to treat migraine include Inderal (propanolol). The tricyclic antidepressants are also commonly used and are effective in migraine prophylaxis–drugs such as Elavil (amitriptyline). Recently a number of anti-seizure drugs have demonstrated their efficacy in migraine prevention. Topiramate is one such drug which had gained much popularity in recent years. It is marketed under the brand name Topamax. The calcium channel blockers are also used. A popular drug in this class used for migraine prophylaxis is verapamil.

Changing your lifestyle and identifying your migraine triggers is the key to achieving good control of these disabling headaches. Common migraine triggers are:

1) Lack of sleep

2) Too much sleep–lets assume you normally sleep for 7 hours a night, now one night you oversleep–it is possible you may wake up with a headache.

3) Alcohol intake–migrainers have a more sensitive brain and thus if they drink too much, it can trigger off an attack. They are especially sensitive to red wine and it is best to avoid it.

4) Certain foods act as migraine triggers–commonly implicated are aged cheeses and chocolate.

5) Excessively stimulating environment–example you go to a rock concert:  loud music, bright lights, a beer here and there–the perfect migraine combo.


Doctors frequently ask their patient’s to maintain a headache diary. This is basically a diary maintained by the patient in which the patient documents each and every headache attack. What precipitated it, what brought on relief from the headache, things eaten around that time etc. If you maintain a good headache diary for a month, you shall be able to identify your migraine triggers and thus avoid them.


1) Familial hemiplegic migraine–as the name suggests it is familial, meaning that it runs in the family. In this special type of migraine, patients usually develop episodic hemiplegia (weakness/ numbness on one half of the body) around the time the headache attack occurs. The hemiplegia resolves once the attack of migraine is over. Familial hemiplegic migraine is thought to occur due to vasoconstriction (spasm of the blood vessels of the brain).

2) Retinal artery migraine–as the name suggests, here the migraine process involves the retinal artery and does presents with visual symptomatology.

3) Basilar artery migraine–here the migraine process involves the basilar artery or its branches in the brain-stem. Patients have sign and symptoms reflecting involvement of the artery and superficially it may seem that they are having a stroke.

4) A number of migraine variants have been described in young children. Young children may not have the classical headache, or they may be unable to express that they are having headaches. A few of the migraine variants described in children include:

a) benign paroxysmal vertigo—children have episodic attacks of vertigo and may throw up during an attack.

b) abdominal migraine-children present with episodic abdominal pain.

c) alternating hemiplegia of childhood–here children have weakness which shifts from one side of the body to the other.



Your  mind is your best friend and your worst enemy

Lord Krishna in the Bhagavad Gita

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