headache — and describe danger signals of headaches that are caused by more serious medical conditions. We also look at the characteristics of headaches formerly known as mixed and now folded into the diagnosis of migraine. (As a reminder: This book is educational and does not diagnose, so please get a diagnosis from your healthcare provider.)
The International Classification of Headache Disorders, 3rd edition (the beta version, abbreviated here as ICHD-3 beta), defines and codes headache types so that doctors can diagnose and prescribe treatments for their patients.1 Created by a committee of the International Headache Society, this diagnostic tool classifies headaches by characteristics, symptoms, and frequency into approximately three hundred types and subtypes, ranging from episodic to chronic and primary to secondary.
With a mind-body approach, we don’t use the classifications for diagnosis and prescription. Instead, by knowing your headache type, you can demystify your symptoms and know which practices and therapies to turn to and when. Can you find your headache type below? Do any of the definitions fit your diagnosis or what you had suspected? Keep in mind that research and definitions evolve over time, and your symptoms may span several categories. As a neurologist specializing in headache noted — of course, all this was decided by a committee, and patients often don’t fit into neat categories.
Types of Headaches
The following definitions include qualitative, somatic descriptions and ICHD-3 beta classification parameters.
Tension-Type Headache
Popularly known as tension headache, tension-type headache is the most common and least-researched headache type. It is characterized by tightness and pressure on both sides of the head, and the pain, which is steady, dull, and nonpulsating, is compared to a tight hatband or having one’s head stuck in a vise. People often complain of a stuck, knot-like pain in the lower skull, back of the neck, shoulders, upper back, or jaw. Tension headache was previously termed muscle contraction headache because those areas can feel tender, tight, and contracted. Tension headache can last from thirty minutes to a week.
Routine physical activity does not tend to make these headaches worse, nor are they accompanied by nausea or vomiting, as in migraine. Nevertheless, they can be debilitating. Some people with tension headache are sensitive to light or sound. If tension headache occurs fifteen or more days per month for three months or more and is not due to medication overuse, the diagnosis changes from episodic to chronic tension-type headache.
Migraine
Migraine is a primary disorder that is characterized by recurrent, debilitating attacks of throbbing, pulsing, or pounding pain, usually located at the sides and front of the head and face, especially forehead and temples. Despite its origins in the Latin term hemicrania — meaning “half skull,” because the pain is often one-sided — migraine can affect one or both sides of the head. During an episode, the pain can even move around — or migrate from one side to the other. An episode typically lasts four to seventy-two hours and is often accompanied by other symptoms.
Migraine is divided into two main subtypes. Migraine without aura (previously termed common migraine) is the most common. Migraine with aura, previously termed classic migraine, is preceded or accompanied by a set of neurological symptoms, collectively termed aura, that can last from several minutes to an hour. Visual disturbances are the most common aura type and can take the form of scintillations — such as flickering lights, spots, or lines — and scotoma, a loss of some or all of a visual field that is otherwise normal. Other types of auras are described as pins and needles on one side of the body or face, numbness, and speech disturbances. Aura symptoms are completely reversible but can be alarming, especially before you are diagnosed, because they are so unusual.
Additionally, migraine can have premonitory symptoms (also called the prodrome phase) that occur two to forty-eight hours before an episode. These symptoms include neck stiffness; sensitivity to light, sound, and odors; fatigue; elation; depression; unusual hunger; particular food cravings; yawning; and pallor.
Symptoms can also manifest during the resolution or recovery phase of the migraine. Although this phase, called the postdrome, is not included in the ICHD-3 beta, many patients report a distinct phase following their migraines. It can last from six to twenty-four hours and has nonheadache symptoms similar to those of the other phases, including most frequently fatigue and neck pain, also light, sound, and odor sensitivities, disorientation, and appetite loss.2
Two important subtypes of migraine are menstrual migraine, which occurs just before or at the beginning of the menstrual cycle, and menstrual-related migraine, which presents at other times during the month in addition to the menstrual migraine pattern.3 (There’s more about migraine and hormones in chapter 8.)
Migraine sufferers seek the stimulus-free environment of a dark, quiet room. They are sensitive to light, odors, sound, and touch; and they have visual field disturbances and mood changes. Even the slightest movement can set off a wave of associated symptoms, including nausea and vomiting. These symptoms can feel just as debilitating as the head pain.
When complicated by other factors, such as muscle tension or medication overuse, a migraine can last for weeks or months, turning it into a chronic condition. Migraine is diagnosed as chronic when episodes occur more than fifteen days per month over a period of three months, provided they are not caused by medication overuse.
Headaches Formerly Known as Mixed
Many people get symptoms of tension headache along with their migraine. This headache type was previously termed coexisting migraine and tension-type headache and prior to that was known as the mixed headache syndrome.
In ICHD-3 beta, this combination of symptoms is no longer classified as a distinct headache type; instead, the symptoms associated with tension-type headache are folded into the diagnosis of chronic migraine. These headaches often begin in tight, painful points or contracted areas in the lower skull, neck, shoulders, or upper back (commonly in the same spot each time). The pain migrates to the entire head or to specific areas in the forehead, temples, and face, where it escalates into pulsing, pounding pain, accompanied by nausea, vomiting, and other migraine symptoms.
Medication-Overuse Headache
Medication-overuse headache (MOH) is caused by regular and extended use of medication — whether prescription, nonprescription, or a combination of both. It is diagnosed when a headache is present on fifteen or more days per month. These headaches can be caused by taking one or more acute or symptomatic treatment drugs ten times per month, or about two days per week, for three months.
This headache type is considered secondary because it is caused by something more — in this case, use of medication. Formerly called rebound, drug-induced, or medication-misuse headache, this condition has become so common, due to the growing preponderance of medications taken to treat headache and migraine, that these diagnostic categories were created in response.
In addition to headache frequency, diagnosis of MOH is determined by the class of medication that is being overused, including ergotamine, triptan, analgesic, opioid, a combination of acute-use medications or analgesics, and other medication not specifically taken for headache. Pain-relief preparations that combine analgesics, barbiturates, or opioids with caffeine are designed for short-term use, and if overused or taken over time, they can transform episodic, occasional migraine into a chronic condition.
Cluster Headache
