According to the World Health Organization, 50 to 75% of people have had a headache in the last year. Headaches present in many different fashions, but all negatively impact a normal lifestyle. Common causes include stress, muscular tightness, nerve irritation and vascular issues. Headaches impact mood, escalate irritability and can be debilitating. Headaches are not normal, and are an alert for a change. This article covers the primary headache classifications, their distinctions, and treatment options. Understanding your headache is the first step in a successful treatment.

What It Is

As a blanket term, headache simply refers to pain in the head. However, there are several different types of headaches, all which are treated very differently. Correctly determining the classification of the headache is crucial for selecting the right treatment. Examples include pain at the back of the head (occipital), front of the head (above the eyebrows - frontal), jaw pain, eye pain, pain that squeezes the head, sinus pain, neck pain, and temporal pain (near the temple).

The most frequently encountered headache classifications are migraine, tension, cervicogenic and cluster, which are detailed below.

Migraine Headaches

The term migraine originally comes from the Greek word hemicrania meaning half the head. 20% of migraines will experience a flash of light before the pain ensues. The painful migraines typically follow a pattern. Typically, the following symptoms precede attacks: excessive tiredness, excessive urination, stiffness, visual disturbances, sensitivity to movement. Because of this, many migraines are correlated with painkillers or caffeine, along with anxiety, depression and sleep loss. The tendency to migraine is genetic and will rise and fall in people's lives. They can be managed, very successfully, and sadly, 40% of people suffering from chronic migraines aren't even made aware that they can be drastically reduced.

The International Classification of Headache Disorder's diagnostic criteria fora migraine denote the following: At least 5 attacks of the following criteria (1-3)

Headache attacks lasting 4-72 hours (untreated).
Headache has at least two of the following four characteristics: On one side of the head, pulsing, moderate to sever pain intensity, aggravated by physical routine.
During headache at least one of the following: nausea/vomiting or sensitivity to light

Cervicogenic headaches

The cervical spine is a biomechanical marvel.

It is a highly versatile mechanism that houses the brain, spinal cord, and major blood vessels to the brain, while supporting the 14 lb. skull. It displays all the rigidity, strength, and leverage required in the job of a crane, while in contrast, must be extremely elastic and flexible. This column of bones must be perfectly balanced to distribute the weight of the skull through the spine. If it's out of balance, the spinal joints misalign, placing abnormal stress on the nerve pathways, soft tissues and muscles of the spine. One manifestation of these are cervicogenic headaches.

Cervicogenic headaches (CEH) are headaches that originate from various anatomic structures of the cervical (neck) spine. They are headaches that are worsened by neck movement, awkward head position or external pressure on the spine. Because of the complexity of the cervical spine, the pathogenesis and etiology of CEH can be a challenge for healthcare professionals.

A 2010 study from Cephalgia, the author reports that medication is often given to combat pain inside the head. A 3-year study of medical intervention in patients with CEH found no improvements in the frequency or duration. They found that often, patients exhibited medication overuse headaches following treatment. The study concluded that pharmacological medication treatment is ineffective and insufficient in evidence. This is likely due to the fact that medication (chemical intervention) does nothing to address a mechanical problem.

The same study listed above examined a surgical procedure of injecting a medication into the greater occipital nerve. By blocking the nerve chemically, 90% of patients reported relief in their symptoms temporarily. While this number is well for acute relief, evidence is lacking for long term resolution of symptoms. Drs. from Cedar Sinai pain center report that additional nerve blocks are done to keep symptoms under control. Following three blocks, treatment progresses into cutting of the nerve, poisoning the nerve with radiation to kill it, or to insert a mechanical device to regulate stimulation of the nerve (similar to a pacemaker)

This model fails to examine the true mechanism of origin for CEH headaches. For any readers who strongly want to understand why their headaches exist, Dr. Bogduk, a clinical neurologist who published an article in 2004 reports that CEH headaches are "likely due to convergence of afferents of the trigeminal and upper three spinal nerves onto the second-order neurons in the trigemino-cervical nucleus in the cervical spinal cord. This most commonly occurs at the craniovertebral junction, which is primarily stabilized by the suboccipital triangle musculature, joint capsules, tectorial membrane, along with transverse and alar ligaments."

These big words boil down to one simple explanation:

When our head and neck are not aligned in their proper position, extra stress is placed on anatomical structures that impede nerve function. This mechanical obstruction to movement is best treated through mechanical (not surgical or chemical) intervention.

A Dutch study found that joint mobilization was effective in a 50% reduction of CEH headaches. A Danish study found a 59% improvement in headache duration and a 36% decrease in intensity. An Australian study showed significant reduction in headache frequency and intensity. An American control trial found SMT to be effective. The review of evidence found that current trials indicate joint mobilization and manipulation to be an effective treatment in the management of CEH.

Diagnostic criteria:

B. Clinical and/or imaging evidence of a disorder of the cervical spine or soft tissues of the neck

C. Evidence of causation demonstrated by at least two of the following:

1. Headache has developed in temporal relation to the onset of the cervical disorder.

2. Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder.

3. Cervical range of motion is reduced, and headache is made worse by provocative maneuvers.

4. Headache is abolished following diagnostic blockage of a cervical structure or it's nerve supply.

Tension Headaches

Tension headaches are the most common form of headache, making up 78% of headache diagnoses by medical professionals. They are often diagnosed by their pain pattern, which is pressing or tightening in quality; of mild to moderate intensity; bilateral in location (both sides of head) in a band/hat-like manner; and does not worsen with physical activity. They do not present with nausea or vomiting.

These headaches are given the name 'tension' because they often arise from muscles and soft tissue, and they are closely related to CEH headaches. Typically, the pain from muscular tension is due to muscles at the base of the skull and shoulder girdle.

These headaches arise when our muscles overwork to hold our head in proper position, and it is predictably linked to prolonged poor posture. When the muscular tension gets too high, our body will produce pain in an effort to spark a change. Initially, these episodes may be episodic. However, a model by Bendtsen et al. has demonstrated that prolonged tension is responsible for the conversion from episodic to chronic. This implies that if we ignore WHY the muscles are tight, these headaches can worsen and progress.

Cluster Headache

Cluster headaches are a very rare form of primary headaches that affect up to 0.1% of the population. They often attack one side of the head, often right behind the eye. These attacks are characterized by severe, intense, burning pain. The pain is frequently reported to be worse than childbirth, and because this is one of the most painful conditions known to humankind, this headache has been dubbed the "suicide headache." The attacks tend to be relatively short, peaking in intensity within 15 minutes. They typically last around 45-90 minutes, but never more than 180.

These attacks tend to affect men more than twice as often as women. They have a tendency to occur at night, and they have a tendency to be regular and predictable. There is a strong correlation to suggest they may be triggered by heavy alcohol consumption or very strong smells.

Most evidence shows that this is a neuro-vascular event. The pain comes from vascular changes that are caused by nerve outflow from the brainstem connection between the trigeminal and facial nerve. The affected nerve causes the local blood vessels to change pressure, resulting in the pain. In addition to the pain above, below and behind the eye, during attacks, patient's eye (same side) will often water, become red and discomforted. The patient will report nasal congestion, throat swelling and flushing as well.

These headaches may progress from episodic to chronic. Therefore, it is important to assess lifestyle changes that may bring about the routine of these headaches. It is equally important to make sure that the brainstem is under the least amount of pressure and stress as possible.

What It Is Not

Headaches are rarely a sign of something scary or dangerous. If a headache occurs very suddenly and is associated with trauma, pain, dizziness or loss of vision, loss of speech, numbness in your face and/or hands, unrelenting horrible pain, nausea, vomiting or loss of consciousness, seek emergency medical attention immediately.

Conclusion

The cervical is a highly versatile mechanism that houses the brain, spinal cord, and major blood vessels to the brain, while supporting the 14 lb. skull. It displays all the rigidity, strength, and leverage required in the job of a crane, while in contrast, must be extremely elastic and flexible. This column of bones must be perfectly balanced to distribute the weight of the skull through the spine. If it's out of balance, the spinal joints misalign, placing abnormal stress on the nerve pathways, soft tissues and muscles of the spine. This mechanical obstruction to movement is best treated through mechanical (not surgical or chemical) intervention.

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Sources

Chaibi, Aleksander, and Michael Bjørn Russell. “Manual therapies for cervicogenic headache: a systematic review.” The journal of headache and pain vol. 13,5 (2012): 351-9. doi:10.1007/s10194-012-0436-7

Chowdhury, Debashish. “Tension type headache.” Annals of Indian Academy of Neurology vol. 15,Suppl 1 (2012): S83-8. doi:10.4103/0972-2327.100023

Knackstedt, Heidi, et al. “Cervicogenic Headache in the General Population: the Akershus Study of Chronic Headache.” Cephalalgia : an International Journal of Headache, U.S. National Library of Medicine, Dec. 2010, www.ncbi.nlm.nih.gov/pubmed/20974607/.

“Occipital Block.” Cedars Sinai, www.cedars-sinai.org/programs/pain-center/conditions-treatments/occipital-block.html.

Weatherall, Mark W. “The diagnosis and treatment of chronic migraine.” Therapeutic advances in chronic disease vol. 6,3 (2015): 115-23. doi:10.1177/2040622315579627

Wei, Diana Yi-Ting et al. “Cluster Headache: Epidemiology, Pathophysiology, Clinical Features, and Diagnosis.” Annals of Indian Academy of Neurology vol. 21,Suppl 1 (2018): S3-S8. doi:10.4103/aian.AIAN_349_17

Headache Overview