What are the different types of headaches?

Types of Headaches

Headaches are broadly classified into primary and secondary types, with primary headaches being those not attributable to another underlying condition, while secondary headaches result from specific medical conditions or factors. 1, 2

Primary Headache Disorders

1. Migraine

Migraine is one of the most common and disabling primary headache disorders, affecting approximately 12% of the population 2. Key characteristics include:

• Migraine without aura:

  • Recurrent attacks lasting 4-72 hours (2-72 hours in children)
  • At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by physical activity
  • At least one of: nausea/vomiting or both photophobia and phonophobia 3

• Migraine with aura:

  • Affects about one-third of migraine patients
  • Features fully reversible aura symptoms that typically develop gradually (≥5 minutes)
  • Aura symptoms occur in succession and are often unilateral 3

• Chronic migraine:

  • Headache occurring on ≥15 days/month for >3 months
  • Fulfills migraine criteria on ≥8 days/month 1, 3
  • Associated with greater disability and economic burden than episodic migraine 1

• Vestibular migraine:

  • Characterized by vestibular symptoms of moderate/severe intensity
  • Occurs with current or previous history of migraine 3

2. Tension-Type Headache

Tension-type headache is the most prevalent primary headache disorder, affecting approximately 38% of the population 2. Characteristics include:

• Bilateral location
• Pressing or tightening quality (non-pulsating)
• Mild to moderate intensity
• Not aggravated by routine physical activity
• No nausea or vomiting (though mild photophobia or phonophobia may be present) 1

3. Trigeminal Autonomic Cephalalgias (TACs)

This group includes several distinct headache disorders characterized by unilateral pain and autonomic symptoms 4:

• Cluster headache:

  • Affects ~0.1% of the general population
  • Strictly unilateral, severe or very severe intensity
  • Short-lasting attacks (15-180 minutes)
  • Accompanied by ipsilateral cranial autonomic symptoms (conjunctival injection, lacrimation, nasal congestion)
  • Often occurs in clusters or "bouts" 1, 4

• Paroxysmal hemicrania:

  • Similar to cluster headache but with shorter, more frequent attacks
  • Responds absolutely to indomethacin 4

• Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT):

  • Very brief attacks of unilateral pain
  • Accompanied by prominent autonomic features 4

• Hemicrania continua:

  • Continuous unilateral headache with fluctuations in intensity
  • Shares features of both migraine and TACs
  • Responds absolutely to indomethacin 4

4. Other Primary Headaches

This category includes several less common primary headache disorders, such as:

• Primary stabbing headache
• Primary cough headache
• Primary exercise headache
• Primary thunderclap headache
• Hypnic headache
• New daily persistent headache 5, 6

Secondary Headache Disorders

Secondary headaches are caused by underlying medical conditions and include:

• Vascular disorders: Subarachnoid hemorrhage, arterial dissection, cerebral venous thrombosis
• Neoplastic causes: Brain tumors, meningiomas, intracranial osteomas 7
• Infectious causes: Meningitis, encephalitis, sinusitis
• Intracranial pressure disorders: Idiopathic intracranial hypertension (pseudotumor cerebri), spontaneous intracranial hypotension
• Medication-overuse headache (MOH): Important differential diagnosis for chronic migraine, develops from overuse of acute headache medications 1
• Head and neck trauma: Post-traumatic headache
• Disorders of homeostasis: Headache attributed to hypoxia, dialysis, arterial hypertension
• Substance use or withdrawal: Alcohol-induced headache, caffeine withdrawal 1

Diagnostic Approach

When evaluating headaches, clinicians should look for "red flags" that suggest a secondary headache requiring further investigation:

• Thunderclap headache (sudden onset)
• Atypical aura
• Head trauma history
• Unexplained fever
• Impaired memory
• Focal neurological symptoms
• Age >50 years at headache onset
• Presence of cancer or immunosuppression
• Headache provoked by physical activities or postural changes 1, 2

Neuroimaging (preferably MRI) should only be used when secondary headache is suspected based on red flags in the history or examination. Routine neuroimaging for primary headache disorders is not recommended and may lead to incidental findings that cause unnecessary anxiety 1.

Common Diagnostic Pitfalls

• Mistaking migraine aura for transient ischemic attack (TIA) - migraine aura typically spreads gradually (≥5 min), while TIA symptoms have sudden onset 3
• Failing to diagnose both migraine with and without aura in patients who experience both types 3
• Overlooking chronic migraine in patients with frequent headaches 3
• Misdiagnosing "sinus headache" when symptoms are actually migraine with cranial autonomic symptoms 1
• Confusing medication-overuse headache with chronic migraine 3

Using headache diaries and validated screening tools like the ID-Migraine questionnaire or Migraine Screen Questionnaire can help improve diagnostic accuracy 1.