Types of headaches and when one is an emergency

In February 2011, British actress Emilia Clarke, then 24 and just back from filming the first season of "Game of Thrones," was working out at a gym in London when she felt a headache coming on. She wanted to keep going anyway. During the plank, she later said, the pain turned into the feeling of an elastic band squeezing her brain. She nearly crawled to the locker room and vomited as the pain kept getting worse.

At the hospital, scans showed a subarachnoid hemorrhage: bleeding from an aneurysm, a bulge in a brain artery that had burst. She needed emergency surgery. Years later, she described the episode in an essay in The New Yorker.

Cases like hers are rare. The vast majority of headaches are not dangerous. But her story shows why it pays to know the types of headaches and to recognize when a severe one needs help right away.

How many types of headache are there?

Many. The International Classification of Headache Disorders (ICHD-3), which the Brazilian Headache Society has translated into Portuguese, describes dozens of types and subtypes. In everyday life, the most useful split is between two big groups.

Primary headaches are those in which the pain is the problem itself, with no other disease behind it: migraine, tension-type headache and cluster headache. Secondary headaches are a symptom of something else, such as the flu, a sinus infection, a blow to the head, overuse of pain medication or, far more rarely, a serious problem in the brain.

According to the World Health Organization (WHO), headache disorders affect about 40% of the world's population, the equivalent of 3.1 billion people in 2021, and are more common in women. The WHO also ranks migraine as the third-largest cause of burden among neurological diseases, measured in years of life lost to early death or lived with disability. Even so, only a minority of people get a proper diagnosis and follow-up.

What does each type of headache feel like?

Each type hurts in its own way. Knowing the differences helps you describe the pain at an appointment.

Tension-type headache

This is the most common kind. It feels like pressure or tightness, often like a band around the head, and it can spread to or start from the back of the neck. It is usually tied to stress or tight neck muscles. The WHO says that in some populations, more than 70% of people have occasional episodes. They last from minutes to a few days. When the pain shows up on 15 or more days a month for over three months, it is called chronic and disrupts daily life far more.

Migraine

Migraine comes in attacks that, untreated, last 4 to 72 hours. If an attack goes past 72 hours, get urgent care. The pain is usually moderate or severe and throbbing, often on one side or behind the eye, and it gets worse with simple activity, like climbing stairs. Nausea, vomiting and sensitivity to light and noise come with it.

Some people get an aura before the pain: passing symptoms such as bright spots, zigzag lines, gaps in vision or tingling. An aura usually lasts up to an hour. If it lasts longer than an hour, get urgent care. If it comes with weakness, numbness on one side of the body, slurred speech or confusion, call emergency services (192 in Brazil). If it is the first time you have ever had an aura, even without those signs, go to an emergency room or urgent care the same day. Migraine is more common in women, possibly because of hormones, and can be triggered by stress, skipped meals and, in women, menstruation, according to the NHS, the United Kingdom's public health service.

Cluster headache

It is rare: it affects fewer than 1 in 1.000 adults and is far more common in men, at a ratio of six men to one woman, according to the WHO. The pain is extremely intense, centered in or around one eye, and arrives in short attacks that can repeat several times a day. On the same side as the pain, the eye turns red and waters, the nose runs or clogs, and the eyelid may droop. The name comes from the way attacks show up: in periods, or "clusters," that can last weeks or months.

Medication-overuse headache

It sounds contradictory, but the medicine you take to relieve pain can, when taken too often, keep the pain going. The WHO estimates that this condition affects up to 5% of the population in some places, women more than men. It shows up in people who already had headaches and began taking pain medication very frequently. Under the international classification, the diagnosis requires headache on 15 or more days a month and use of acute medication on 10 or 15 days a month (depending on the type of drug) for more than three months. The pain is usually present most days and can be worse on waking.

The message is simple: if you take medicine for headaches several times a week, talk to a doctor rather than raising the dose on your own. RaisLife has also covered the correct use of medications.

What are the most common causes of headaches?

Most of the time, there is an everyday reason. The NHS lists these among the most common causes:

• colds and the flu;
• stress;
• too much alcohol;
• poor posture and vision problems;
• skipped meals and not drinking enough water;
• pain medication taken too often;
• menstruation and menopause, because of shifting hormones.

Infections with fever also tend to bring a bad headache. In dengue, a mosquito-borne illness common in Brazil, it is one of the most typical symptoms, along with pain behind the eyes and body aches. See the symptoms and warning signs of dengue.

The WHO recommends keeping a headache diary: write down the day, the time, how long it lasted, what you were doing, what you ate, how you slept and whether you took any medicine. Within a few weeks, the notebook often reveals triggers you had not noticed and helps at the appointment. The WHO also points to simple habits, such as moderating alcohol, keeping regular sleep hours, exercising, eating well and staying hydrated.

A severe headache: when is it an emergency?

A severe headache does not always mean serious disease. A migraine or cluster attack can hurt a great deal and still not threaten your life. What changes everything is how the pain arrives and what comes with it.

The best-known warning sign is the thunderclap headache: very severe pain that peaks in under a minute, like an explosion, the "worst headache of your life." The international classification warns that this kind of pain can be linked to serious problems in the blood vessels of the brain, above all a subarachnoid hemorrhage like Emilia Clarke's, and that imaging and other tests are needed.

Call emergency services (SAMU 192 in Brazil) or go to the emergency room if a headache comes with any of these signs:

• it started suddenly and is extremely severe;
• high fever, a stiff neck or strong discomfort in bright light;
• skin spots that do not fade when you press a glass against them;
• weakness or numbness in the face, an arm or a leg;
• trouble speaking, walking, keeping your balance or remembering things;
• drowsiness or confusion;
• loss of vision;
• a seizure;
• a blow to the head in the past three months.

In these situations, do not drive yourself to the hospital. Have someone take you, or call an ambulance.

When to see a doctor

Outside of emergencies, some signs call for same-day care, at an emergency room or an urgent care unit (in Brazil, a UPA, a 24-hour urgent care unit), as soon as possible and not at a basic health unit (a UBS, Brazil's neighborhood primary care clinic):

• headache with changes in vision;
• jaw pain when chewing or a tender scalp;
• pain with a red, painful eye and halos around lights;
• pregnant women and women who recently gave birth with a headache, at the emergency room, urgent care or maternity hospital, especially after week 20 or with swelling, vision changes or high blood pressure;
• a new headache in people with cancer, a weakened immune system or who take blood thinners.

These other signs call for urgent care, the same day or in the following days, at a basic health unit, an urgent care unit or with an on-call doctor:

• pain that starts or gets worse when coughing, sneezing, bending over or straining;
• headache with vomiting;
• a child whose pain keeps getting worse or wakes them at night;
• pain that does not improve, or gets worse, despite the usual measures;
• a new headache after age 50;
• frequent headaches, or needing pain medicine several times a week.

The NHS classes vision changes, jaw or scalp pain, pain that worsens with coughing or straining, vomiting and a child whose pain is getting worse as urgent. A new headache after 50, pregnancy and the postpartum period, acute glaucoma (a red eye with halos) and high-risk conditions, by contrast, are classic red flags in the medical literature on secondary headaches. The split between emergency room, urgent care unit and basic health unit is this portal's adaptation to Brazil's public health system, the SUS, and not an NHS rule.

The first step can be a general practitioner or family doctor, including at a basic health unit. If the pain is frequent, changes pattern or does not improve with the initial follow-up, the right specialist is a neurologist.

The bottom line: know your pain to know when to hurry

Emilia's pain came on strong, with vomiting, and kept getting worse. She was taken to the hospital and operated on. Her case shows that some signs cannot wait.

For most people, headaches will remain tension-type or migraine: annoying and sometimes disabling, but not life-threatening. Understanding your own pattern and seeking help when attacks become frequent makes a difference. A sudden, explosive headache, or one with fever and a stiff neck, or with neurological signs, is a case for emergency services.

Frequently asked questions

Is a headache every day normal?

It should not be treated as normal. A headache on most days can be chronic pain or linked to overuse of painkillers, and it deserves a medical visit.

What is the difference between migraine and an ordinary headache?

Migraine comes in attacks lasting hours to days, usually throbs, gets worse with exertion and often brings nausea or vomiting and/or sensitivity to light and noise. Tension-type pain is more of a squeeze, generally without nausea; there may be mild sensitivity to light or noise.

Can a severe headache be a stroke?

It can, especially when it is sudden and explosive or comes with weakness, slurred speech, loss of vision or confusion. In those cases, call emergency services right away (SAMU 192 in Brazil).

Sources

• World Health Organization (WHO). Headache disorders (fact sheet). who.int
• Sociedade Brasileira de Cefaleia (Brazilian Headache Society). International Classification of Headache Disorders, 3rd edition (ICHD-3), Portuguese translation. sbcefaleia.com.br
• NHS (United Kingdom). Headaches. nhs.uk
• NHS (United Kingdom). Migraine. nhs.uk
• NHS (United Kingdom). Cluster headaches. nhs.uk
• Clarke E. A Battle for My Life. The New Yorker, 2019. newyorker.com

Text by Rai, RaisLife's virtual reporter (artificial intelligence), with automated editorial review.