Types of Headache

Whenever a person experiences a headache, the first step involved is to categorize the type of headache by the neurologist. A great majority of headaches arise due to benign conditions. ICHD-3 criteria should be used to recognize the type of headache a patient is experiencing. This chapter will not just give you insight into diagnostic criteria but also the management of each type of headache.

Primary Category
Headache & Pain
Secondary Category


  • Defined as pain or discomfort in the head.
  • One of the most common symptoms reported to clinicians.
  • A great majority of headaches arise due to benign conditions.
  • It necessitates thorough investigation because, sometimes, it can represent an early manifestation of a possibly grave disorder.


Classification per International Classification of Headache Disorder (ICHD), 3rd Ed

Part 1: The Primary Headaches
  1. Migraine
  1. Tension-type headache
  1. Trigeminal autonomic cephalgia
  1. Other primary headache disorders
Part 2: The Secondary Headaches—Headache (or Facial Pain) Attributed to:
  1. Trauma or injury to the head and/or neck
  1. Cranial or cervical vascular disease
  1. Nonvascular intracranial disorder
  1. A substance or its withdrawal
  1. Infection
  1. Disorder of homeostasis
  1. Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure
  1. Psychiatric disorder
Part 3: Painful Cranial Neuropathies, Other Facial Pains, and Other Headaches
  • Painful cranial neuropathies and other facial pain
  • Other headache disorders
Source: The American Journal of Medicine (2018) 131, 17–24.Headache, Paul Rizzoli, MD, FAHS, William J. Mullally, MD, FAHS. Graham Headache Center, Brigham and Women’s Faulkner Hospital, Harvard Medical School, Boston, Mass. https://doi.org/10.1016/j.amjmed.2017.09.005


  • Lifelong prevalence of headaches is 96%, with a female predominance.
  • Global prevalence of Tension-type headache and Migraine is 40% and 10%, respectively.
  • Migraine occurs between ages 25 to 55 years, 3 times more common in women.
  • Cluster headache has a population prevalence of 0.1% and a male/female ratio of 3.5-7:1.
  • Worldwide prevalence of chronic daily headaches has been consistent at 3%-5%, which mostly represents Chronic Migraine.



  • Caused presumably by genetically induced hypersensitivity of the brain.
  • Arises from the activation and sensibilization of the trigeminovascular system.
  • Results in the release of neuropeptides and other substances.
  • Both cause local inflammation and distant amplification of neural circuitry in the brainstem, trigeminal nucleus caudalis, thalamus, and cortex, leads to central sensitization and symptom worsening.
  • Reduced activity in central descending inhibitory systems and reduced ability to control or extinguish the headache attack.
  • Hypothalamus, a higher brain center, is involved in initiation of migraine attack.
  • Calcitonin-gene related peptide (CGRP) is involved in migraine.

Cluster headache

  • Imbalance between the sympathetic and parasympathetic neural system causes cranial-autonomic symptoms.
  • Calcitonin-gene related-peptide (CGRP) is also involved in cluster headaches.

Tension-type headaches

  • Greater role played by environmental factors.
  • Contributing factors; tenderness of pericranial muscles, co-existing mood disorders, and mechanical disorders of the spine and neck.
  • Peripheral and central sensitization are relevant in chronification of migraine and tension-type headache.

Common Precipitating Factors


  • Skipping meals
  • Too much or too little sleep
  • Stressful events
  • Smoking
  • Depression or anxiety
  • Drinking too much alcohol, particularly red wine
  • Loud or sudden noises
  • Processed meats that contain nitrates, aspartame, MSG, aged cheese, and chocolate
  • Birth control pills or hormone replacement therapy
  • Headache medicine used on a daily or near daily basis
  • Menstruation

Cluster Headache

  • More common in those who smoke
  • Head trauma, such as an injury or surgery

Tension-type Headache

  • Arthritis in the neck
  • Changing hormone levels for females, due to the menstrual cycle, pregnancy and menopause, among other situations and conditions
  • Fatigue from sleep deprivation or other causes
  • Injury to the head or neck area
  • Anxiety
  • Depression
  • Eye, neck or back strain caused by poor posture
  • Stress
  • Teeth grinding and jaw clenching

Diagnostic Criteria

ICHD-3 Criteria for Migraine Without Aura

  • A. At least 5 headache attacks fulfilling the criteria B-D
  • B. Attacks last 4-72 h
  • C. With at least 2 of the following 4 characteristics:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe pain intensity
    • Aggravation by or causing avoidance of routine physical activity
  • D. At least 1 of the following during headache:
    • Nausea and/or vomiting
    • Photophobia and phonophobia
  • E. Not better accounted for by another ICHD-3 diagnosis

ICHD-3 Criteria for Migraine with Aura

  • A. At Least two attacks fulfilling criteria B and C
  • B. One or more of the following fully reversible aura symptoms:
    • Visual
    • Sensory
    • Speech and/or language
    • Motor
    • Brainstem
    • Retinal
  • C. At least two of the following characteristics:
    • At least one aura symptom spreads gradually over ≥5 minutes, and/or two or more symptoms occur in succession
    • Each individual aura symptom lasts 5-60 minutes
    • At least one aura symptom is unilateral
    • The aura is accompanied, or followed within 60 minutes, by headache
  • D. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded

ICHD-3 Criteria for Cluster Headache

  • A. At least five attacks fulfilling criteria B–D
  • B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)
  • C. Either or both of the following:
    • At least one of the following symptoms or signs, ipsilateral to the headache:
      • a) Conjunctival injection and/or lacrimation
      • b) Nasal congestion and/or rhinorrhoea
      • c) Eyelid edema
      • d) Forehead and facial sweating
      • e) Forehead and facial flushing
      • f) Sensation of fullness in the ear
      • g) Miosis and/or ptosis
    • A sense of restlessness or agitation
  • D. Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active

ICHD Criteria for Episodic Tension-type Headache


Detailed History

  • Family history of migraine
  • Childhood migraine proxy symptoms: car sickness, gastrointestinal complaints.
  • Age of onset
  • Frequency, severity, and tempo over time
  • Triggering, aggravating, or alleviating features
  • Autonomic features
  • Aura features
  • Current and prior treatments
    • Drugs and toxins exposure
    • Anticoagulants
  • Lifestyle features; IV drug user (risk of infection)
  • Comorbid conditions
    • Immunosuppressive disorders
    • Hypertension (risk of hemorrhage)
    • Malignancy (risk of metastasis)
    • Dementia
    • Coagulopathy
  • General physical examination to rule out secondary causes. Should include,
    • Cardiovascular assessment
    • Fundoscopy
    • Palpation of head and face
    • Tonometry to rule out Acute Angle Closure Glaucoma.

Neurologic examination

  • Mental status
  • Level of consciousness
  • Cranial nerve testing particularly II, III, IV and VI
  • Pupillary responses
  • Motor strength testing
  • Deep tendon reflexes
  • Sensation
  • Pathologic reflexes (e.g. Babinski's sign)
  • Cerebellar function and gait testing
  • Signs of meningeal irritation (Kernig's and Brudzinski's signs)

‘Red Flags’ indicating further need for imaging

  • New headache in older patients
  • Abnormal neurologic examination including papilledema and change in mental status
  • New change in headache pattern or progressive headache
  • New headache in the setting of HIV risk factors, cancer, or immunocompromised status
  • Signs of a systemic illness (eg, fever, stiff neck, rash)
  • Triggered by cough, exertion, Valsalva maneuver
  • Headache in pregnancy/postpartum period
  • First or worst headache


  • CT-scan.
  • MRI scan (more sensitive in identifying intracranial pathologies)
  • Lumbar Puncture, if CT-scan is negative to rule out Subarachnoid Hemorrhage

Differential Diagnosis

  • Tumors, particularly pituitary masses
  • Abscess
  • Hemorrhage (bleeding within the brain)
  • Bacterial or viral meningitis (an infection or inflammation of the membrane that covers the brain and spinal cord)
  • Pseudotumor cerebri (increased intracranial pressure)
  • Hydrocephalus (abnormal build-up of fluid in the brain)
  • Infection of the brain
  • Encephalitis (inflammation of the brain)
  • Blood clots
  • Head trauma
  • Sinus blockage or disease
  • Malformation (such as Arnold-Chiari)
  • Injuries
  • Infections, such as Lyme disease
  • Meningitis
  • Aneurysm
  • Temporal Arteritis
  • West Nile Virus
  • Carbon monoxide poisoning

Further Reading

Rizzoli, P., & Mullally, W. J. (2018). Headache. The American Journal of Medicine, 131(1), 17–24. https://doi.org/10.1016/j.amjmed.2017.09.005


  1. The International Classification of Headache Disorders - ICHD-3. (2021). Retrieved 13 September 2021, from https://ichd-3.org/
  1. Headache Rizzoli, Paul et al. The American Journal of Medicine, Volume 131, Issue 1, 17 - 24
  1. PMC E. Europe PMC [Internet]. Europepmc.org. 2021 [cited 13 September 2021]. Available from: https://europepmc.org/abstract/MED/3248935
  1. Spierings, E., Ranke, A., & Honkoop, P. (2021). Precipitating and Aggravating Factors of Migraine Versus Tension-type Headache.
  1. Headaches: Types, Symptoms, Causes, Diagnosis & Treatment. Cleveland Clinic. (2021). From https://my.clevelandclinic.org/health/diseases/9639-headaches.
  1. Headache Causes. Mayo Clinic. (2021). From https://www.mayoclinic.org/symptoms/headache/basics/causes/sym-20050800.
  1. Risk Factors for Headache | Winchester Hospital. Winchesterhospital.org. (2021). From https://www.winchesterhospital.org/health-library/article?id=19555.
  1. Headache. From https://www.healthgrades.com/right-care/migraine-and-headache/headache#risk-factors.
  1. PRIME PubMed | Precipitating and relieving factors of migraine versus tension type headache. Neuro.unboundmedicine.com. (2021). From https://neuro.unboundmedicine.com/medline/citation/22920541/Precipitating_and_relieving_factors_of_migraine_versus_tension_type_headache_.
  1. Clinch, C. (2021). Evaluation of Acute Headaches in Adults. Aafp.org. From https://www.aafp.org/afp/2001/0215/p685.html#afp20010215p685-t4.
  1. Approach to the Patient With Headache - Neurologic Disorders - MSD Manual Professional Edition. MSD Manual Professional Edition. (2021). From https://www.msdmanuals.com/professional/neurologic-disorders/headache/approach-to-the-patient-with-headache.
  1. Just In Time Medicine. Differential Diagnosis of Headache. Justintimemedicine.com. (2021). From https://www.justintimemedicine.com/CurriculumContent/p/6830.
  1. Gilmore, B., & Michael, M. (2021). Treatment of Acute Migraine Headache. Aafp.org. From https://www.aafp.org/afp/2011/0201/p271.html.
  1. Headache Management. Research.birmingham.ac.uk. (2021). From https://research.birmingham.ac.uk/portal/files/20437602/Sinclair_et_al_Headache_management_practneurol_2015_001167.full.pdf.
  1. What Are the Symptoms of a Headache?. Verywell Health. (2021). From https://www.verywellhealth.com/headache-symptoms-1719563.
  1. Tension headache: Background, pathophysiology, etiology. (2021, July 12). Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/792384-overview#a7
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