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Introduction

Almost everyone gets a headache once in a while, and some unlucky people have them almost every day. Usually we pay little attention to them—we take a couple of Tylenol, and in a few hours the headache is gone. But sometimes headaches become so painful or so frequent that we start to worry: could it be the symptom of a brain tumor or the warning sign of an oncoming stroke?

The good news about headaches is that the vast majority of headaches are completely harmless. However, every once in a while a headache is a warning of some serious—or even deadly—condition. So how do you tell?

Old Versus New Headaches

There’s an old joke in which a worried patient asks, “Doc, what have I got?”
“Have you had it before?” the doctor asks.
“Yes,” the patient replies.
“Well,” the doctor announces, “you’ve got it again.”

There’s an important lesson in this joke; sometimes the most important fact about your symptom is whether it’s happened to you before. This is especially true with headaches.

Chronic Headaches

You might think that the longer you’ve been suffering from headaches, the more likely they are to be dangerous. In fact, the opposite is true—the longer you’ve been suffering from headaches, the less likely it is that they indicate some serious condition. As a rule, any sort of headache that you’ve had many times over a period of several years, without developing any other symptoms, is almost certain to be harmless. Doctors call these chronic headaches. The two most common types of chronic headache are tension-type headaches and migraines.

Tension Headaches

Tension-type headaches usually feel like a tight band around the head, or just an aching pain all over the head. The name tension suggests that these headaches are brought on by emotional tension, or that they are caused by some sort of tension in the muscles of the neck and head. In fact, it’s not clear how significant a role either type of tension plays in these headaches. It’s certainly true that some people do get this sort of headache toward the end of a stressful day, and sitting or working in awkward positions can bring them on.

Migraine Headaches

Migraine headaches are slightly different. The pain of migraine is usually a pounding rather than tight feeling. Instead of being all over the head, migraine pain is usually much worse on one side, and often seems to be centered around or behind one eye. For this reason, many people with migraine mistakenly attribute their headaches to eye strain or sinus trouble. Many people feel nauseated during a migraine, and because light and sound become painful, they want to lie down in a dark, quiet room until the headache passes. Some people see shimmering zig-zags of light and color move across their field of vision several minutes before their headache starts, something referred to as an aura.

Even though migraine is very common, we still don’t understand why some people are cursed with it, or exactly what goes on inside the head to cause the headache. Some people will have one or two migraine headaches in a lifetime, while others have them almost daily. Migraine headaches can be excruciating, and frequent migraines can completely disrupt a person’s daily life. The treatment of migraine is too complicated a subject to discuss here, but there are ways both to prevent migraine headaches, and to relieve them when they do happen.

When to Worry

Since chronic headaches are almost never anything to worry about, when should you worry? As a general rule, doctors are most concerned about new headaches. If you suffer from occasional headaches, a new headache means a headache that feels different from any you’ve had before. If you never get headaches, any headache is new. Are all new headaches dangerous? No. The great majority of new headaches turn out to be harmless, too. Many turn out to be migraine or tension-type headaches—after all, everyone with chronic migraines must have had a first, new headache at the beginning. But if you are having new headaches, you should have them evaluated by a physician.

Doctors worry most about three specific types of new headaches. They are:

“Thunderclap” headaches

Headaches with fever

Headaches with other symptoms

Thunderclap headaches
Headaches that hit suddenly, and are severe from the moment they start, are called thunderclap headaches. They are a concern because one of their causes are subarachnoid hemorrhages—where one of the arteries that run across the surface of the brain ruptures, causing blood to pour into the fluid that surrounds and cushions the brain. These hemorrhages are very dangerous and potentially fatal. They usually occur when there is a spot along the artery where it widens, creating a little bump or bubble called an aneurysm. Aneurysms are weak spots, where the artery can rupture and bleed. When people talk about “having an aneurysm” they are referring to subarachnoid hemorrhage, though doctors don’t use this phrase.

Although there are also harmless causes of thunderclap headache, any sudden, severe headache that lasts more than a few minutes should be evaluated immediately by a doctor, preferably in the emergency room. In contrast, sudden but brief headaches—jabs or jolts of pain that last anywhere from a few seconds to a minute or so—are almost always harmless.

Headache and fever
Headache and fever can be symptoms of meningitis. The word meningitis itself just means inflammation or infection of the tissue (called the meninges) and fluid that surround and protect the brain and spinal cord. Not all forms of meningitis are dangerous—many common viruses, for example, can cause viral meningitis, which is unpleasant, but usually harmless. Bacterial meningitis, on the other hand, is a different matter; these infections can be fatal if they’re not treated quickly with antibiotics. This is the kind of meningitis you hear about in the news, often striking several children in the same school.

Does this mean that you should rush to the ER every time you have a fever and a headache? No. Many unpleasant but harmless infections like the common cold and flu can cause fever and headache, and these infections are thousands of times more common than bacterial meningitis. So how do you know when to be concerned? Again, you should use your own experience as a guide. If your symptoms feel like those of colds or flus you’ve had before, then you should not be alarmed. If, however, your illness feels unfamiliar—the headache is worse, or you feel much sicker than ever before—you should see a doctor promptly. Anyone with headache and fever who is drowsy or confused needs medical attention immediately. The safest course is to go to the emergency room.

Headache with other symptoms
Migraine headaches, which are harmless, often come with other symptoms—like nausea, sensitivity to light and sound, and shimmering lights and colors. This shows that headaches accompanied by other symptoms aren’t always worrisome, especially if they’re chronic, as migraine often is. As a rule, though, if you develop other symptoms, either during a headache, or between headaches, you must have your headaches evaluated by a physician. These symptoms include:

Trouble speaking
Blurry vision, double vision, or brief “blackouts” of vision
Weakness, numbness, clumsiness, or tingling in one arm, one leg, or one side of the face
Trouble with walking or balance
A spinning sensation (what doctors call vertigo)
Drowsiness or confusion
New headaches with migraine-like symptoms of nausea, vomiting, lights or colors in vision

Common Fears

There are a number of conditions many headache-sufferers fear.

Brain tumors
Everyone who suffers from headaches (even if they’re a doctor) worries at some point that they might have a brain tumor. We’ve all seen those movies in which someone’s terrible headaches—which, of course, they try to ignore—turn out to be caused by an incurable tumor.

The truth is, headaches are not the first sign that you’ve got a brain tumor. Other symptoms first signal this problem. Difficulty writing or speaking, weakness or clumsiness in a limb, an epileptic seizure—these are the sort of symptoms that signal trouble (though these symptoms can also be caused by many conditions other than tumors). In fact, most brain tumors don’t cause any headache at all, and when they do, these headaches are usually quite mild, not the sort of thing that would send you to the emergency room. During more than ten years working in the emergency department I have—unfortunately—seen many people with brain tumors, but not one of them came in because of headache.

High blood pressure
Many people assume that their headaches are caused by high blood pressure. Actually, high blood pressure (also called hypertension) is a very uncommon cause of headache. Most people with hypertension have no symptoms at all—that’s why it is referred to as the “silent killer.”

Strokes
Many people worry that a particularly severe headache either is a stroke, or will lead to one. Neither is true. A stroke occurs when a part of the brain is suddenly damaged—either when a small artery in the brain becomes blocked, or when an artery ruptures and bleeds inside the brain. The symptoms of a stroke depend on which part of the brain is damaged, and they can include any of the other neurological symptoms listed earlier, such as weakness on one side or trouble with speech. Most strokes are completely painless. Sometimes a person will develop a headache at the time of a stroke, but the other symptoms make it clear that it is a stroke, not an ordinary headache.

Can a severe headache cause a stroke? No, though this can be hard to believe if you’re suffering through an awful migraine. Once in a while, though, new headaches warn us about a condition, like severe hypertension, that can lead to stroke. This is yet another reason to have new headaches evaluated by a physician.

Conclusion

A headache is rarely a sign of anything serious. If headaches are disrupting your life, don’t be afraid—see a doctor. Many medical centers have departments that specialize in the treatment of headache. They can put your mind at ease—and make your head feel a lot better.