1. Tension-type
2. Migraine
3. Cluster

For more information, please click on FAQ for each headache type

Tension-type headache is the most common headache type, and 70% people have them at one time or another. Every year, more than 90% of people in the United States experience some type of headache. Tension-type headaches may be associated with tense muscles, but this is not true in all cases, and it is also true in migraine at times.

What it feels like: Patients describe tension-type headache as being felt on both sides of the head as pressing, aching, squeezing, or a tight feeling. Although it can occur anywhere in the head, it's usually experienced in the forehead, in the temples, the top of the head, the back of the head, or as a band around the head. Tension-type headache does not throb or pound; the ache or pain is usually mild or moderate in intensity and does not interfere with normal activities. In contrast to migraine, physical activity or exertion does not aggravate the pain. Although patients with tension-type headache may be sensitive to light or sound (but not to both), these headaches are rarely associated with nausea or vomiting.

Migraine headache is a type of headache that occurs 1 to 4 times per month in "episodes," and affects more women than men. The tendency toward migraine headache is inherited, and migraine seems to "run in families".

Migraine headache is often one sided but can be experienced on both sides of the head. It is often described as throbbing in character, but it can also be steady and nonthrobbing. The table below shows its distinguishing characteristics.

People with migraine:

Must have at least two of these: Moderate or severe pain One-sided headache Throbbing, pulsating pain Pain that worsens with mild physical activity	Must have at least one of these: Nausea Vomiting Sensitivity to both light and sound
Other Symptoms often Associated with Migraine:
Poor appetite Tearing eyes Diarrhea Stuffed nose Runny nose Visual disturbance Speech problems Increased frequency of urination	Dizziness Sleep problems Cold hands and feet Restlessness Sweating Neck pain Yawning Temporarily elevated blood pressure

About 15% of those with migraine have an aura, which is a set of symptoms that warn them before the head pain begins. Most auras are visual and last 20 to 30 minutes, but an aura can also be weakness, numbness, or speech problems.

"Aura" means wind, and it refers to specific neurological symptoms that may occur before a migraine headache begins and rarely during a migraine headache. About 15% of people who have migraine headache experience aura as a warning phenomenon. Some even experience the aura without the headache, which is known as a "migraine equivalent" or "migraine aura without headache".

The most commonly experienced aura is visual, in which patients see many small, colored dots, flashing bright lights, or multicolored zigzag lines that may form a shimmering overall crescent-like shape. The jagged lines are also known as "fortification spectra" because they resemble the jagged outlines of forts built during the Middle Ages. [[Scan figure 3.1 from Conquering Headache, first edition.]]

There are two major types of migraine: migraine with aura, previously known as classic migraine; and migraine without aura, previously common migraine.

Migraine with Aura About 15% of migraineurs (people with migraine) have a warning that consists of neurologic signs before the migraine episode begins. Aura symptoms typically last for 20 to 30 minutes and are followed within 5 to 60 minutes by the headache. Aura symptoms that last more than one hour may be a sign of other neurological problems and should be brought to a physician's attention. The headache that follows the aura is similar to a migraine headache without aura.

Sinus problems only occasionally cause headache, no matter what TV ads for decongestants, allergy, and cold remedies may say. Although sinus problems may cause headache, they usually do not, and many patients with headaches and sinus problems do not "lose" their headaches after their sinus problems have been properly (and effectively) treated.

When sinus headaches do occur, they are usually due to inflammation of the mucous membranes that line the sinuses of the head and face or to infection due to blockage of the sinus drainage system. Patients have pain in the sinuses of the forehead or cheeks, a postnasal drip, fever, red and tender skin over the sinuses, and appear sick.

Allergies usually do not cause severe headaches, but since some patients with migraine or tension-type headache also have allergies and because a headache may occur at the same time as allergy symptoms, many assume that the headache is the result of the allergy. There is, however, an exception: your sinuses fill up during "allergy season" (grass and pollen), and headache may result. These headaches usually respond to appropriate anti-allergy treatment. Headaches that do not respond to treatment of the allergies are probably migraine or tension-type headaches, or are related to overuse of pain medicines (analgesic rebound headache). More information on rebound headache What is migraine? What is Tension-Type Headache?

Many migraineurs (people with migraine) find that they must retreat to a dark and quiet room because light and noise worsen their headaches. Many find that sleep helps. When it is not practical or possible to do this, migraine may respond to a combination of aspirin, acetaminophen, and caffeine, as found in Excedrin Migraine Strength. It may also respond to plain aspirin, acetaminophen (non-aspirin pain reliever, Tylenol), or other over-the-counter products. If over-the-counter medications do not relieve the pain and you think you may have migraine headache, it is important to consult a physician because a migraine attack can often be stopped in its tracks with prescription medication. Midrin may help for mild forms of migraine.

Triptans are a new class of medications that have been effective for many people in ending a migraine attack. Sumatriptan (Imitrex), which is available in a self-injection, a tablet, and a nasal spray, was the first to become available. Zolmitriptan (Zomig) tablets have recently been introduced. A dihydroergotamine -- DHE -- nasal spray (Migranal) has recently become available. Other classes of medication such as the beta blockers, calcium channel blockers, antiseizure medications, and serotonin blockers, all of which are taken daily, have been approved by the FDA for prevention of migraine.

People who are not headache prone do not usually get headaches under stressful conditions. Those who are prone to headache, however, may experience headache when under stress or after a stressful period has passed, during the so-called letdown period.

Re: Tension-type headache: These headaches are sometimes associated with muscle tension and sometimes emotional tension. Emotional stress may, of course, result in tense muscles about the head and neck.

Re: Migraine headache: Some people with migraine headache have attacks while under stress; others are fine until the stressful events have passed and get into trouble during the letdown, such as after things have returned to normal or during a vacation that follows a stressful period. Surprisingly, they may get a migraine attack while relaxing on a beach, even though they are free of responsibility.

It depends upon what kind of medicine you are taking, of course, but a good rule of thumb is not to take any pain medication more than three days in any week, and no more frequently than recommended on the label or as prescribed. If you need more medication than that to control pain, it is important to consult a physician.

For more information, go to rebound headache

Headaches can be worsened by the overuse of off-the-shelf and prescription pain relievers (analgesics), barbiturates, caffeine, and ergotamine tartrate, resulting in analgesic rebound headache.

Off-the-shelf pain relievers include aspirin, acetaminophen, ibuprofen, ketoprofen, naproxen sodium, and combination products that contain aspirin, acetaminophen, and caffeine.

Typically, analgesic rebound headache occurs when people who start out by taking small amounts of off-the-shelf or prescription medication increase their use to four or more days per week. They notice that their headaches gradually worsen and require increasing amounts of pain relievers to control them. The headaches then become increasingly difficult to control, and they feel worse rather than better.

This is not a time to take more or stronger medications, because escalating the medications can in turn worsen the rebound phenomenon if the medications are used frequently, or it can even result in dependence on certain prescription pain relievers.

Could you have rebound headache? Click here for a discussion of signs and symptoms.

A typical rebound headache lasts between 4 and 24 hours, with mild to moderate, dull, nonthrobbing, steady pain in any part of the head. People who experience it may feel pain in the forehead or on the top or in the back of the head, but the pain can be all over or in any one place.

The pain of rebound headache is usually on both sides of the head rather than one side. Most people with rebound do not experience such migraine-type symptoms as throbbing, nausea, increased sensitivity to light and sound, or worsening with mild exertion. The pain may, however, intensify to a severe migraine episode.

What can you do about rebound headaches?

The simple solution would be to stop overusing pain relievers. But it isn't that easy. Most patients with analgesic rebound who have tried to stop overusing pain relievers have found that their headaches got worse before they got better. Their headaches typically became more intense within 4 to 6 hours after stopping the medication and were at their worst within 1 to 2 days. This "worst period" may last for two to three weeks.

If this describes you and you have not already consulted a physician, now is the time. The first step is to begin gradually withdrawing the pain relievers. Your doctor may prescribe Midrin, which sometimes eases the pain and withdrawal symptoms, as may nonsteroidal anti-inflammatory medications, antinausea medications, or some tranquilizers.

The process of withdrawal from pain relievers and getting relief of rebound headache is not fast. Most patients notice improvement in their headache symptoms and general feeling of well-being over the next two to three months. Their headaches occur much less frequently and are less severe; they feel much better, sleep better, may be less depressed. In time, they can stop worrying that they may get a headache.

Patients who get to this point may respond to daily preventive medications such as the beta-blockers, calcium blockers, and antidepressants, none of which would have been effective during the height of the analgesic rebound headache.

Withdrawal from ergotamine tartrate has difficulties all its own. Ergotamine withdrawal syndrome usually begins within several hours of missing the accustomed dose of ergotamine and peaks within 1 to 2 days. It may persist for 3 to 5 days and often requires urgent hospitalization. Most treatment -- other than restarting ergotamine tartrate -- is ineffective, and patients often need hospital care, including intravenous dihydroergotamine -- (D.H.E. 45), IV fluids, antinausea medicines, and even IV steroids. But this condiiton, although a real problem, is very treatable and the success rate is high.

Some experts believe that even nonprescription pain relievers may be associated with rebound headache. Most experts agree that butalbital, which is in Fiorinal, Fioricet, Phrenilin, Axocet, and Esgic, and codeine, which is in Fiorinal with codeine, Fioricet with codeine, and Tylenol with codeine, and similar preparations under various brand and generic names play a role in rebound. People who frequently use sedatives and tranquilizers may also experience rebound headache. Sometimes caffeine or ergotamine overuse can lead to rebound.

Worse still, overuse of these medications tends to interfere with the usual effectiveness of daily headache preventive medications, relaxation techniques, and biofeedback training.

Could you have rebound headache? Click here for a discussion of signs and symptoms.

Yes. Overuse of ergotamine tartrate (Wigraine, Cafergot, Ergomar, Ergocap), which is effective in relieving acute migraine, results in an ergotamine rebound syndrome. Surprisingly small amounts of ergotamine tartrate -- as little as a 1 mg tablet three times per week -- can produce this syndrome.

Why? Ergotamine tartrate quickly relieves migraine headache, so patients with rebound may use it for each headache, even a mild one. Soon, their ergotamine-responsive headaches occur more frequently, so they take the medication again.

Ergotamine rebound headaches often begin at a certain time every day, but ergotamine relieves the pain within an hour. The problem may escalate if ergotamine tartrate continues to be taken regularly. If patients stop taking it abruptly, they may develop a severe, prolonged, incapacitating headache that can be accompanied by nausea, vomiting, and diarrhea. Many also become agitated and restless and have difficulty sleeping.

Ergotamine withdrawal syndrome usually begins within several hours of missing the accustomed dose of ergotamine and peaks within 1 to 2 days. It may persist for 3 to 5 days and often requires urgent hospitalization. Most treatment -- other than restarting ergotamine tartrate -- is ineffective, and patients often need hospital care, including intravenous dihydroergotamine -- (D.H.E. 45). IV fluids, antinausea medicines, and even IV steroids. But this condition, although a real problem, is very treatable and the success rate is high.

What can you do about rebound headache?

Caffeine withdrawal headache results when someone does not get the amount of caffeine to which he or she is accustomed. The body reacts to the lack of caffeine in a variety of ways, one of which may be a caffeine withdrawal headache. It is often a throbbing headache that improves when more caffeine is taken.

Caffeine sensitivity varies widely. People who get more than 200 mg of caffeine may experience caffeine withdrawal headache if they do not get their coffee, cola drinks. or other sources of caffeine to which they are accustomed.

What is the caffeine content of various caffeine-containing foods and beverages?

The table below lists the amount of caffeine in foods, beverages, and medications.

Product Example Caffeine (mg) -------------------------- Cocoa and chocolate Baking chocolate, 1 oz 35 Chocolate candy bar 25 Cocoa beverage, 6 oz prepared 10 Milk chocolate, 1 oz 6 Coffee Decaffeinated 2 Drip, 5 oz 146 Instant, regular, 5 oz 53 Percolated, 5 oz 110 Off-the-shelf medicines Anacin 32 Excedrin Extra Strength 65 No-Doz tablets 100-200 Vanquish 33 Vivarin tablets 200 Prescription medicines Darvon Compound-65 32.4 Esgic 40 Fioricet 40 Fiorinal 40 Norgesic 30 Norgesic Forte 60 Soft Drinks (12 oz) 7-Up, Diet 7-Up, Fresca, Ginger Ale, Hires Root Beer 0 Coca-Cola, Diet Pepsi 34 Dr. Pepper 38 Mountain Dew 52 Pepsi Cola 37 Tab 44 Tea (5 oz) 1-minute brew 9-33 3-minute brew 22-46 5-minute brew 20-50 Canned iced tea (12 oz) varies by brand 22-36

It's important to decrease your caffeine intake gradually because abruptly stopping it increases your risk of caffeine withdrawal headache. We recommend that patients at The New England Center for Headache begin by eliminating one portion of caffeine from the daily total and stay at that level for a 5 to 7 days. For example, if you drink 5 cups of coffee per day decrease one cup every 5 days, eliminating another cup the following week, and so on, until you have stopped drinking caffeinated beverages and eating foods that contain caffeine.

Remember to include the caffeine content of medications when you total your daily caffeine intake.

What is the caffeine content of various caffeine-containing foods and beverages?

It depends upon what kind of medicine you are taking, of course, but a good rule of thumb is not to take any pain medication than three days in any week, and no more frequently than recommended on the label or as prescribed. If you need more medication than that to control pain, it is important to consult a physician.

For more information, go to rebound headache