Headache

Type of Headache

Migraine
Tension Headache
Cluster Headache

<Migraine>

A migraine headache can cause intense throbbing or a pulsing sensation in one area of the head and is commonly accompanied by nausea, vomiting, and extreme sensitivity to light and sound.

Migraine attacks can cause significant pain for hours to days and be so severe that all you can think about is finding a dark, quiet place to lie down.

Some migraines are preceded or accompanied by sensory warning symptoms (aura), such as flashes of light, blind spots, or tingling in your arm or leg.

Medications can help reduce the frequency and severity of migraines. If treatment hasn't worked for you in the past, talk to your doctor about trying a different migraine headache medication. The right medicines, combined with self-help remedies and lifestyle changes, may make a big difference.

Migraine headaches often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages, including prodrome, aura, headache and postdrome, though you may not experience all the stages.

Prodrome

One or two days before a migraine, you may notice subtle changes that signify an oncoming migraine, including:

Constipation
Depression
Food cravings
Hyperactivity
Irritability
Neck stiffness
Uncontrollable yawning

Aura

Aura may occur before or during migraine headaches. Auras are nervous system symptoms that are usually visual disturbances, such as flashes of light. Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Most people experience migraine headaches without aura. Each of these symptoms usually begins gradually, builds up over several minutes, and then commonly lasts for 20 to 60 minutes. Examples of aura include:

Visual phenomena, such as seeing various shapes, bright spots or flashes of light
Vision loss
Pins and needles sensations in an arm or leg
Speech or language problems (aphasia)

Less commonly, an aura may be associated with limb weakness (hemiplegic migraine).

Attack

When untreated, a migraine usually lasts from four to 72 hours, but the frequency with which headaches occur varies from person to person. You may have migraines several times a month or much less often. During a migraine, you may experience the following symptoms:

Pain on one side or both sides of your head
Pain that has a pulsating, throbbing quality
Sensitivity to light, sounds and sometimes smells
Nausea and vomiting
Blurred vision
Lightheadedness, sometimes followed by fainting

Postdrome

The final phase, known as postdrome, occurs after a migraine attack. During this time you may feel drained and washed out, though some people report feeling mildly euphoric.

When to see a doctor

Migraine headaches are often undiagnosed and untreated. If you regularly experience signs and symptoms of migraine attacks, keep a record of your attacks and how you treated them. Then make an appointment with your doctor to discuss your headaches. Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

Go to the emergency room
if you have any of the following signs and symptoms, which may indicate other, more serious medical problems:

An abrupt, severe headache like a thunderclap
Headache with fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or trouble speaking
Headache after a head injury, especially if the headache gets worse
A chronic headache that is worse after coughing, exertion, straining or a sudden movement

Although much about the cause of migraines isn't understood, genetics and environmental factors appear to play a role. Migraines may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway. Imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — also may be involved. Researchers continue to study the role of serotonin in migraines.

Serotonin levels drop during migraine attacks. This may cause your trigeminal system to release substances called neuropeptides, which travel to your brain's outer covering (meninges). The result is headache pain.

Migraine headache triggers

Common migraine triggers include:

Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women with known migraines. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen. Others have an increased tendency to develop migraines during pregnancy or menopause. Hormonal medications, such as oral contraceptives and hormone replacement therapy, also may worsen migraines. Some women, however, may find their migraines occur less often when taking these medications.
Foods. Aged cheeses, salty foods and processed foods may trigger migraines. Skipping meals or fasting also can trigger attacks.
Food additives. The sweetener aspartame and the preservative monosodium glutamate, found in many foods, may trigger migraines.
Drinks. Alcohol, especially wine, and highly caffeinated beverages may trigger migraines.
Stress. Stress at work or home can cause migraines.
Sensory stimuli. Bright lights and sun glare can induce migraines, as can loud sounds. Unusual smells — including perfume, paint thinner, secondhand smoke and others — can trigger migraines in some people.
Changes in wake-sleep pattern. Missing sleep or getting too much sleep may trigger migraines in some people, as can jet lag.
Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
Changes in the environment. A change of weather or barometric pressure can prompt a migraine.
Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.

Several factors make you more prone to having migraines.

Family history. Up to 90 percent of people with migraines have a family history of migraine attacks. If one or both of your parents have migraines, then you have a good chance of having migraines too.
Age. Migraines can begin at any age, though most people experience their first migraine during adolescence. By age 40, most people who have migraines have had their first attack.
Sex. Women are three times more likely to have migraines. Headaches tend to affect boys more than girls during childhood, but by the time of puberty and beyond, more girls are affected.
Hormonal changes. If you're a woman who has migraines, you may find that your headaches begin just before or shortly after onset of menstruation. They may also change during pregnancy or menopause. Generally migraines improve after menopause. Some women report that migraine attacks begin during pregnancy, or the attacks may get worse. However, for many, the attacks improved or didn't occur during later stages in the pregnancy.

Sometimes your efforts to control your pain cause problems.

Abdominal problems. Certain pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others), may cause abdominal pain, bleeding, ulcers and other complications, especially if taken in large doses or for a long period of time.
Medication-overuse headaches. If you take over-the-counter or prescription headache medications more than 10 days a month for three months, or in high doses, you may be setting yourself up for a serious complication known as medication-overuse headaches. Medication-overuse headaches occur when medications not only stop relieving pain but also cause headaches. You then use more pain medication, which continues the cycle.

Also, some people experience complications from migraines such as:

Chronic migraine. If your migraine lasted for 15 or more days a month for more than three months, you had a chronic migraine.
Status migrainosus. People with this complication have migraine attacks that last for more than three days.
Persistent aura without infarction. Usually an aura goes away after the migraine attack. However, some people have an aura that lasts for more than one week after a migraine attack has finished. A prolonged aura may have similar symptoms to bleeding in the brain (stroke). In this condition, though, you have a prolonged aura without signs of bleeding in the brain or other problems.
Migrainous infarction. Some people who have a migraine with aura may have aura symptoms that last longer than one hour. This can be a sign of bleeding in the brain (stroke). If you have a migraine with aura, and your aura symptoms last longer than one hour, you should have it evaluated. Doctors can conduct neuroimaging tests to determine if you have bleeding in the brain.

Make an appointment with you primary care doctor if you have symptoms and signs. After initial evaluation, you may be referred to a doctor trained in evaluating and treating headaches (neurologist). Because appointments can be brief, and because there's often a lot to talk about, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

Write down symptoms you're experiencing, even if they seem unrelated to your migraines.
Write down key personal information, including any major stresses or recent life changes.
Make a list of all medications, vitamins or supplements that you're taking. It's particularly important to list all medications, as well as the dosages you have used to treat your headaches.
Keep a headache diary. A diary can help you and your doctor determine what triggers your migraines. Note when your headaches start, how long they last and what, if anything, provides relief. Be sure to record your response to any headache medications you take. Also note the foods you ate in the 24 hours preceding attacks, any unusual stress, and how you feel and what you're doing when headaches strike.
Reduce stress. Because stress triggers migraines for many people, try to avoid overly stressful situations, or use stress-reduction techniques like meditation.
Get enough sleep. Aim for a regular sleep schedule and get an adequate amount of sleep.

Your doctor may recommend a variety of tests to rule out other possible causes for your pain if your condition is unusual, complex or suddenly becomes severe.

Blood tests.
Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of your brain. This helps doctors diagnose bleeding in your brain and other possible medical problems that may be causing your headaches.
Magnetic resonance imaging (MRI). An MRI uses a powerful magnetic field and radio waves to produce detailed images of your brain and blood vessels. MRI scans help doctors diagnose tumors, strokes, bleeding in your brain, infections, and other brain and nervous system (neurological) conditions.
Spinal tap (lumbar puncture). If your neurologist suspects an underlying condition, such as infections or bleeding in your brain, he or she may recommend a spinal tap (lumbar puncture). In this procedure, a thin needle is inserted between two vertebrae in your lower back to extract a sample of cerebrospinal fluid for laboratory analysis.

Migraines can't be cured, but doctors will work with you to help you manage your condition.

A variety of medications have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:

Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun.
Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Choosing a strategy to manage your migraines depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.

Some medications aren't recommended if you're pregnant or breast-feeding. Some medications aren't given to children. Your doctor can help find the right medication for you.

Pain-relieving medications

For the most effective results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine. It may help if you rest or sleep in a dark room after taking them. Medications include:

Pain relievers. Aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin, others), may help relieve mild migraines.
Pain relievers, such as acetaminophen (Tylenol, others), also may help relieve mild migraines in some people. Drugs marketed specifically for migraines, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraine pain, but aren't effective alone for severe migraines. If taken too often or for long periods of time, these medications can lead to ulcers, gastrointestinal bleeding and medication-overuse headaches.
Triptans. Many people with migraine attacks use triptans to treat their migraines. Triptans work by promoting constriction of blood vessels and blocking pain pathways in the brain. Triptans effectively relieve the pain and other symptoms that are associated with migraines. Medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax). Some triptans are available as nasal sprays and injections, in addition to tablets.
Side effects of triptans include nausea, dizziness, drowsiness and muscle weakness. They aren't recommended for people at risk of strokes and heart attacks.
Ergots. Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergotamine may cause worsened nausea and vomiting related to your migraines and other side effects, and it may also lead to medication-overuse headaches.
Anti-nausea medications. Because migraines are often accompanied by nausea, with or without vomiting, medication for nausea is appropriate and is usually combined with other medications. Frequently prescribed medications are chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro).

Preventive medications

You may be a candidate for preventive therapy if you have four or more debilitating attacks a month, if attacks last more than 12 hours, if pain-relieving medications aren't helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness. Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks.

Your doctor may recommend that you take preventive medications daily, or only when a predictable trigger, such as menstruation, is approaching.

To prevent or reduce the frequency of your migraines, take these medications as your doctor recommends:

Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines.
The beta blockers propranolol (Inderal La, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are also sometimes used for treatment of migraine. You may not notice improvement in symptoms for several weeks after taking these medications. Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure and keep blood vessels from becoming narrow or wide, also may be helpful in preventing migraines and relieving symptoms from migraines. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help you. In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines.
Antidepressants. Certain antidepressants help to prevent some types of headaches, including migraines. Tricyclic antidepressants may be effective in preventing migraines. You don't have to have depression to benefit from these drugs. Tricyclic antidepressants may reduce the frequency of migraine headaches by affecting the level of serotonin and other brain chemicals. Amitriptyline is the one of the tricyclic antidepressant proved to effectively prevent migraine headaches. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline.
Anti-seizure drugs. Some anti-seizure drugs, such as valproate sodium (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraine headaches.
OnabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) has been shown to be helpful in treating chronic migraine headaches in adults. During this procedure, injections are made in muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks.
Pain relievers. Taking nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.

Self-care measures can help ease the pain of a migraine headache.

Try muscle relaxation exercises. Relaxation may help ease the pain of a migraine headache. Relaxation techniques may include progressive muscle relaxation, meditation or yoga.
Get enough sleep, but don't oversleep. Get an adequate amount of sleep each night. It's best to go to bed and wake up at regular times, as well.
Rest and relax. If possible, rest in a dark, quiet room when you feel a headache coming on. Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp.
Keep a headache diary. Continue keeping your headache diary even after you see your doctor. It will help you learn more about what triggers your migraines and what treatment is most effective.

Nontraditional therapies may be helpful if you have chronic migraine pain:

Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.
Massage therapy. Massage therapy may help reduce the frequency of migraines. Researchers continue to study the effectiveness of massage therapy in preventing migraines.
Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines.
Herbs, vitamins and minerals. There is some evidence that the herb butterbur may prevent migraines or reduce their severity.
Another herb, feverfew, may help prevent migraines, but it has shown mixed results in studies.
A high dose of riboflavin (vitamin B-2) also may prevent migraines or reduce the frequency of headaches.
Coenzyme Q10 supplements may decrease the frequency of migraines, but they have little effect on the severity of the headache.
Due to low magnesium levels in some people with migraines, magnesium supplements have been used to treat migraines, but with mixed results.

Whether or not you take preventive medications, you may benefit from lifestyle changes that can help reduce the number and severity of migraines. One or more of these suggestions may be helpful for you:

Avoid triggers. If certain foods or odors seem to have triggered your migraines in the past, avoid them. Your doctor may recommend you reduce your caffeine and alcohol intake and avoid tobacco. In general, establish a daily routine with regular sleep patterns and regular meals. In addition, try to control stress.
Exercise regularly. Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches. Obesity is also thought to be a factor in migraine headaches, and regular exercise can help you maintain a healthy weight or lose weight.
Reduce the effects of estrogen. If you're a woman who has migraines and estrogen seems to trigger or make your headaches worse, you may want to avoid or reduce the medications you take that contain estrogen. These medications include birth control pills and hormone replacement therapy. Talk with your doctor about the appropriate alternatives or dosages for you.

<Tension Headache>

A tension headache is generally a diffuse, mild to moderate pain in your head that's often described as feeling like a tight band around your head. A tension headache (tension-type headache) is the most common type of headache, and yet its causes aren't well understood.

Treatments for tension headaches are available. Managing a tension headache is often a balance between fostering healthy habits, finding effective nondrug treatments and using medications appropriately.

Signs and symptoms of a tension headache include:

Dull, aching head pain
Sensation of tightness or pressure across your forehead or on the sides and back of your head
Tenderness on your scalp, neck and shoulder muscles

Tension headaches are divided into two main categories — episodic and chronic.

Episodic tension headaches can last from 30 minutes to a week. Frequent episodic tension headaches occur less than 15 days a month for at least three months. Frequent episodic tension headaches may become chronic.
Chronic tension headaches lasts hours and may be continuous. If your headaches occur 15 or more days a month for at least three months, they're considered chronic.

Tension headaches can be difficult to distinguish from migraines. Plus, if you have frequent episodic tension headaches, you can also have migraines. Unlike some forms of migraine, tension headache usually isn't associated with visual disturbances, nausea or vomiting. Although physical activity typically aggravates migraine pain, it doesn't make tension headache pain worse. An increased sensitivity to either light or sound can occur with a tension headache, but these aren't common symptoms.

When to see a doctor

Make an appointment with your primary care doctor if tension headache disrupts your life or you need to take medication for your headaches more than twice a week.

Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different. Occasionally, headaches may indicate a serious medical condition, such as a brain tumor or rupture of a weakened blood vessel (aneurysm).

If you have any of these signs or symptoms, seek emergency care:

Abrupt, severe headache
Headache with a fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or speaking difficulties
Headache after a head injury, especially if the headache gets worse

Stress is the most commonly reported trigger for tension headaches.

Risk factors for tension headache include:

Being a woman. One study found that almost 90 percent of women and about 70 percent of men experience tension headaches during their lifetimes.
Being middle-aged. The incidence of tension headaches appears to peak in the 40s, though people of all ages can get this type of headache.

Because tension headaches are so common, their effect on job productivity and overall quality of life is considerable, particularly if they're chronic. The frequent pain may render you unable to attend activities. You might need to stay home from work, or if you do go to your job, your ability to function is impaired.

Make an appointment to see your primary care doctor. After initial evaluation, you then may be referred to a doctor who specializes in treating nervous system disorders, such as headache (neurologist).

Here's some information to help you get ready for your appointment and to know what to expect from your doctor.

What you can do

Write down any symptoms you're experiencing, including any that may seem unrelated to your headaches.
Write down key personal information, including major stresses or recent life changes.
Make a list of all medications, vitamins or supplements you're taking, and share this information with your doctor.
Write down questions to ask your doctor.

For tension headaches, some basic questions to ask your doctor include:

What type of headache do you think I'm experiencing?
What tests do I need? What will these tests rule out?
Is my condition likely temporary or chronic?
What treatments are available? Which do you recommend?
What are the alternatives to the primary approach you're suggesting?
I have other health conditions. How can I best manage them together?
Are there restrictions I need to follow?
Do I need to see a specialist?
Is there a generic alternative to the medicine you're prescribing?
What are common side effects of the medications you're prescribing?
Do you have brochures or other printed material I can take home? What websites do you recommend?

Don't hesitate to ask other questions, as well.

What to expect from your doctorYour doctor will likely ask you questions, such as:

When did you begin experiencing symptoms?
Have you noticed any common triggers, such as stress or hunger?
Have your symptoms been continuous or occasional?
How severe are your symptoms?
How often do you have headaches?
How long does each headache last?
What, if anything, seems to improve your symptoms?
What, if anything, appears to worsen your symptoms?

What you can do in the meantimeWhile you're waiting to see your doctor, you can take an over-the-counter painkiller, such as ibuprofen (Advil, Motrin IB, others) or acetaminophen (Tylenol, others) to temporarily relieve the pain.

Keep a headache diary. To gather information about your headaches that will help your doctor, keep a headache diary. For each headache, jot down:

Date. Charting the date and time of each headache can help you recognize patterns.
Duration. How long did your headache last?
Intensity. Rate your headache pain on a scale from 1 to 10, with 10 being the worst.
Triggers. List possible triggers of your headache, such as certain foods, physical activities, noise, stress, smoke, bright lights or changes in weather.
Symptoms. Did you have symptoms before you got the headache?
Medications. What medications have you taken? List any, including dosage, even if they're unrelated to your headache.
Relief. Have you experienced any pain relief and from what?

If you have chronic or recurrent headaches, your doctor may conduct physical and neurological exams, then try to pinpoint the type and cause of your headaches using these approaches:

Your pain descriptionYour doctor can learn a lot about your headaches from a description of your pain. Be sure to include these details:

Pain characteristics. Does your pain pulsate? Or is it constant and dull? Sharp or stabbing?
Pain intensity. A good indicator of the severity of your headache is how much you're able to function while you have it. Are you able to work? Do your headaches wake you or prevent you from sleeping?
Pain location. Do you feel pain all over your head, on only one side of your head, or just on your forehead or behind your eyes?

Imaging testsIf you have unusual or complicated headaches, your doctor may order tests to rule out serious causes of head pain, such as a tumor. Two common tests used to image your brain include:

Computerized tomography (CT). A CT scan is a diagnostic imaging procedure that uses a series of computer-directed X-rays to provide a comprehensive view of your brain.
Magnetic resonance imaging (MRI). An MRI scan combines a magnetic field, radio waves and computer technology to produce clear images.

Some people with tension headaches don't seek medical attention and try to treat the pain on their own. Unfortunately, repeated use of over-the-counter (OTC) pain relievers can actually cause overuse headaches.

A variety of medications, both OTC and prescription, are available to reduce the pain of a headache, including:

Pain relievers. Simple OTC pain relievers are usually the first line of treatment for reducing headache pain. These include the drugs aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve). Prescription medications include naproxen (Naprosyn), indomethacin (Indocin) and ketorolac (Ketorolac Tromethamine).
Combination medications. Aspirin or acetaminophen or both are often combined with caffeine or a sedative drug in a single medication. Combination drugs may be more effective than are single-ingredient pain relievers. Many combination drugs are available OTC.
Triptans and narcotics. For people who experience both migraines and episodic tension headaches, a triptan can effectively relieve the pain of both headaches. Opiates, or narcotics, are rarely used because of their side effects and potential for dependency.

Preventive medicationsYour doctor may prescribe medications to reduce the frequency and severity of attacks, especially if you have frequent or chronic headaches that aren't relieved by pain medication and other therapies.

Preventive medications may include:

Tricyclic antidepressants. Tricyclic antidepressants, including amitriptyline and nortriptyline (Pamelor), are the most commonly used medications to prevent tension headache. Side effects of these medications may include weight gain, drowsiness and dry mouth.
Other antidepressants. There also is some evidence to support the use of the antidepressants venlafaxine (Effexor XR) and mirtazapine (Remeron) in people who don't also have depression.
Anticonvulsants and muscle relaxants. Other medications that may prevent tension headache include anticonvulsants, such as topiramate (Topamax). More study is needed.

Preventive medications may require several weeks or more to build up in your system before they take effect. So don't get frustrated if you haven't seen improvements shortly after you begin taking the drug.

Your doctor will monitor your treatment to see how the preventive medication is working. In the meantime, overuse of pain relievers for your headaches may interfere with the effects of the preventive drugs.

Rest, ice packs or a long, hot shower may be all you need to relieve a tension headache. A variety of strategies can help reduce the severity and frequency of chronic tension headaches without using medicine. Try some of the following:

Manage your stress level. One way to help reduce stress is by planning ahead and organizing your day. Another way is to allow more time to relax. And if you're caught in a stressful situation, consider stepping back.
Go hot or cold. Applying heat or ice — whichever you prefer — to sore muscles, may ease a tension headache. For heat, use a heating pad set on low, a hot-water bottle, a warm compress or a hot towel. A hot bath or shower also may help. For cold, wrap ice, an ice pack or frozen vegetables in a cloth to protect your skin.
Perfect your posture. Good posture can help keep your muscles from tensing. When standing, hold your shoulders back and your head level. Pull in your abdomen and buttocks. When sitting, make sure your thighs are parallel to the ground and your head isn't slumped forward.

The following nontraditional therapies may help if you have tension headache pain:

Acupuncture. Acupuncture may provide temporary relief from chronic headache pain. Acupuncture practitioners treat you using extremely thin, disposable needles that generally cause little pain or discomfort. The American Academy of Medical Acupuncture website provides referrals to medical doctors who use acupuncture in their practices.
Massage. Massage can help reduce stress and relieve tension. It's especially effective for relieving tight, tender muscles in the back of your head, neck and shoulders. For some people, it may also provide relief from headache pain.
Deep breathing, biofeedback and behavior therapies. A variety of relaxation therapies are useful in coping with tension headache, including deep breathing and biofeedback.

Living with chronic pain can be difficult. Chronic pain can make you anxious or depressed and affect your relationships, your productivity and the quality of your life.

Here are some suggestions:

Talk to a counselor or therapist. Talk therapy may help you cope with the effects of chronic pain.
Join a support group. Support groups can be good sources of information. Group members often know about the latest treatments. Your doctor may be able to recommend a group in your area.

In addition to regular exercise, techniques such as biofeedback training and relaxation therapy can help reduce stress.

Biofeedback training. This technique teaches you to control certain body responses that help reduce pain. During a biofeedback session, you're connected to devices that monitor and give you feedback on body functions such as muscle tension, heart rate and blood pressure. You then learn how to reduce muscle tension and slow your heart rate and breathing yourself.
Cognitive behavioral therapy. This type of talk therapy may help you learn to manage stress and may help reduce the frequency and severity of your headaches.
Other relaxation techniques. Anything that helps you relax, including deep breathing, yoga, meditation and progressive muscle relaxation, may help your headaches. You can learn relaxation techniques in classes or at home using books or tapes.

Using medications in conjunction with stress management techniques may be more effective than is either treatment alone in reducing your tension headaches.

Additionally, living a healthy lifestyle may help prevent headaches:

Get enough, but not too much sleep.
Don't smoke.
Exercise regularly.
Eat regular, balanced meals.
Drink plenty of water.
Limit alcohol, caffeine and sugar.

Cluster headaches occur in cyclical patterns or clusters, which gives the condition its name. Cluster headache is one of the most painful types of headache.

Cluster headache commonly awakens you in the middle of the night with intense pain in or around one eye on one side of your head.

Bouts of frequent attacks, known as cluster periods, may last from weeks to months, usually followed by remission periods when the headache attacks stop completely. During remission, no headaches occur for months and sometimes even years.

Fortunately, cluster headache is rare and not life-threatening. Treatments can help make cluster headache attacks shorter and less severe. In addition, medications can help reduce the number of cluster headaches.

A cluster headache strikes quickly, usually without warning. Common signs and symptoms include:

Excruciating pain, generally located in or around one eye, but may radiate to other areas of your face, head, neck and shoulders
One-sided pain
Restlessness
Excessive tearing
Redness in your eye on the affected side
Stuffy or runny nasal passage in your nostril on the affected side of your face
Sweaty, pale skin (pallor) on your face
Swelling around your eye on the affected side of your face
Drooping eyelid

The pain of a cluster headache is often described as sharp, penetrating or burning. People with this condition say that the pain feels like a hot poker being stuck in the eye or that the eye is being pushed out of its socket.

People with cluster headache appear restless. They may pace or sit through the attack. In contrast to people with migraine, people with cluster headache usually avoid lying down during an attack because this position seems to increase the pain.

Some migraine-like symptoms — including nausea, sensitivity to light and sound, and aura — may occur with a cluster headache, though usually on one side.

Cluster period characteristicsA cluster period generally lasts from six to 12 weeks. The starting date and the duration of each cluster period may be consistent from period to period. For example, cluster periods may occur seasonally, such as every spring or every fall.

Most people have episodic cluster headaches. In episodic cluster headaches, the cluster headaches occur for one week to a year, followed by a pain-free remission period that may last as long as 12 months before another cluster headache develops.

Chronic cluster periods may continue for more than a year, or pain-free periods may last less than one month.

During a cluster period:

Headaches usually occur every day, sometimes several times a day.
A single attack may last from 15 minutes to three hours.
The attacks often happen at the same time within each 24-hour day.
The majority of attacks occur at night, usually one to two hours after you go to bed.

The pain usually ends as suddenly as it begins, with rapidly decreasing intensity. After attacks, most people are completely free from pain, but exhausted.

When to see a doctorSee your doctor if you've just started to experience cluster headaches to rule out other disorders and to find the most effective treatment.

Headache pain, even when severe, usually isn't the result of an underlying disease, but headaches may occasionally indicate a serious underlying medical condition, such as a brain tumor or rupture of a weakened blood vessel (aneurysm).

Additionally, if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.

Seek emergency care if you have any of these signs and symptoms:

Abrupt, severe headache, often like a thunderclap
Headache with a fever, nausea or vomiting, stiff neck, mental confusion, seizures, numbness, or speaking difficulties, which may indicate a number of problems, including stroke, meningitis, encephalitis or brain tumor
Headache after a head injury, even if it's a minor fall or bump, especially if it gets worse
A sudden, severe headache unlike any other headache you've experienced
Headache that gets progressively worse over days and changes in pattern

The exact cause of cluster headaches is unknown, but abnormalities in the hypothalamus likely play a role. Cluster attacks usually occur with clocklike regularity during a 24-hour day, and the cycle of cluster periods often follows the seasons of the year.

These patterns suggest that the body's biological clock is involved. In humans, the biological clock is located in the hypothalamus, which lies deep in the center of your brain.

Abnormalities of the hypothalamus may explain the timing and cyclical nature of cluster headache. Imaging studies have detected increased activity in the hypothalamus during the course of a cluster headache.

Unlike migraine and tension headache, cluster headache generally isn't associated with triggers, such as foods, hormonal changes or stress. Some people experience an aura or nausea similar to those experienced with migraine headaches.

Once a cluster period begins, however, consumption of alcohol can quickly trigger a splitting headache. For this reason, many people with cluster headache avoid alcohol for the duration of a cluster period.

Other possible triggers include the use of medications such as nitroglycerin, a drug used to treat heart disease.

Risk factors for cluster headaches include:

Sex. Men are more likely to have cluster headaches.
Age. Most people with cluster headaches first develop the disorder between ages 20 and 50, although the condition can develop at any age.
Smoking. Many people who get cluster headache attacks are smokers.
Alcohol use. Alcohol can trigger an attack if you're at risk of cluster headache.
A family history. If a parent or sibling has ever had a cluster headache, you may have an increased risk of cluster headaches.

You're likely to start by seeing your family doctor. However, you may be referred to a neurologist, a doctor trained in treating brain and nervous system disorders, such as headache.

Because appointments can be brief, and there's often a lot to talk about, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, as well as what to expect from your doctor.

Keep a headache diaryOne of the most helpful things you can do is keep a headache diary. Each time you get a headache, jot down these details that may help your doctor diagnose your particular kind of headache and discover possible headache triggers.

Date. Charting the date and time of each headache can help you recognize patterns.
Duration. How long did your headache last?
Intensity. Rate your headache pain on a scale from 1 to 10, with 10 being the most severe.
Triggers. List possible triggers that may have caused your headache, such as certain foods, sounds, odors, physical activity or oversleeping.
Symptoms. Did you experience any preceding symptoms?
Medications. What medications have you taken? List any, including dosages, even if they're unrelated to your headache.
Relief. Have you experienced any pain relief, from complete pain relief to none?

Your time with your doctor is limited, so preparing a list of questions may help you make the most of your time together. List your questions from most important to least important in case time runs out. For cluster headaches, some basic questions to ask your doctor include:

What's the most likely cause of my symptoms?
Are there other possible causes for my symptoms?
What kinds of tests do I need? What will these tests rule out?
Is my condition likely temporary or chronic?
What treatments are available? Which do you recommend?
What are the alternatives to the primary approach that you're suggesting?
I have other health conditions. How can I best manage them together?
Are there any restrictions that I need to follow?
Do I need to see a specialist?
Is there a generic alternative to the medicine you're prescribing?
What are common side effects to the medications you're prescribing?
Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctorYour doctor will likely ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on later. Your doctor may ask:

When did you begin experiencing symptoms?
Have your symptoms been continuous or occasional?
Do your symptoms tend to occur at the same time of day? Do they occur during the same season each year?
Does alcohol appear to cause your symptoms?
How severe are your symptoms?
What, if anything, seems to improve your symptoms?
What, if anything, appears to worsen your symptoms?

Cluster headache has a characteristic type of pain and pattern of attacks. A diagnosis depends on your description of the attacks, including your pain, the location and severity of your headaches, and associated symptoms. The frequency and duration of your headaches also are important factors.

If you have chronic or recurrent headaches, your doctor may try to pinpoint the type and cause of your headache using certain approaches.

Neurological examinationA neurological examination may help your doctor detect physical signs of a cluster headache. Sometimes the pupil of your eye may appear smaller, or your eyelid may droop, even between attacks.

Imaging testsIf you have unusual or complicated headaches or an abnormal neurological examination, your doctor may recommend other tests to rule out other serious causes of head pain, such as a tumor or aneurysm. Common brain imaging tests include:

Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of your brain.
Magnetic resonance imaging (MRI). An MRI uses a powerful magnetic field and radio waves to produce detailed images of your brain and blood vessels.

There's no cure for cluster headaches. The goal of treatment is to decrease the severity of pain, shorten the headache period and prevent the attacks.

Because the pain of a cluster headache comes on suddenly and may subside within a short time, cluster headache can be difficult to evaluate and treat, as it requires fast-acting medications.

Some types of acute medication can provide some pain relief quickly. Based on the latest studies, the therapies listed below have proved to be most effective for acute and preventive treatment of cluster headache.

Acute treatmentsFast-acting treatments available from your doctor include:

Oxygen. Briefly inhaling 100 percent oxygen through a mask at a minimum rate of at least 12 liters a minute provides dramatic relief for most who use it. The effects of this safe, inexpensive procedure can be felt within 15 minutes.

The major drawback of oxygen is the need to carry an oxygen cylinder and regulator with you, which can make the treatment inconvenient and inaccessible at times. Small, portable units are available, but some people still find them impractical.
Triptans. The injectable form of sumatriptan (Imitrex), which is commonly used to treat migraine, is also an effective treatment for acute cluster headache.

The first injection may be given while under medical observation. Some people may benefit from using sumatriptan in nasal spray form, but for most people this isn't as effective as an injection and it may take longer to work. Sumatriptan isn't recommended if you have uncontrolled high blood pressure or heart disease.

Another triptan medication, zolmitriptan (Zomig), can be taken in nasal spray or tablet form for relief of cluster headache. This medication may be an option if you can't tolerate other forms of fast-acting treatments.
Octreotide. Octreotide (Sandostatin), an injectable synthetic version of the brain hormone somatostatin, is an effective treatment for cluster headache.
Local anesthetics. The numbing effect of local anesthetics, such as lidocaine (Xylocaine), may be effective against cluster headache pain in some people when given through the nose (intranasal).
Dihydroergotamine. The intravenous form of dihydroergotamine (D.H.E. 45) may be an effective pain reliever for some people with cluster headache. This medication is also available in an inhaled (intranasal) form called Migranal, but this form hasn't been proved to be effective.

To have the medication administered through a vein (intravenously), you'll need to go to a hospital or doctor's office to have the medication administered through a vein (intravenously).

Preventive treatmentsPreventive therapy starts at the onset of the cluster episode with the goal of suppressing attacks.

Determining which medicine to use often depends on the length and regularity of your episodes. Under the guidance of your doctor, the drugs can be tapered off once the expected length of the cluster episode ends.

Calcium channel blockers. The calcium channel blocking agent verapamil (Calan, Verelan, others) is often the first choice for preventing cluster headache. Verapamil is often used in conjunction with other medications. Occasionally, longer term use is needed to manage chronic cluster headache.

Side effects may include constipation, nausea, fatigue, swelling of the ankles and low blood pressure.
Corticosteroids. Inflammation-suppressing drugs called corticosteroids, such as prednisone, are fast-acting preventive medications that may be effective for many people with cluster headaches.

Your doctor may prescribe corticosteroids if your cluster headache condition has only recently started or if you have a pattern of brief cluster periods and long remissions.

Although corticosteroids may often be a good short-term option, serious side effects such as diabetes, hypertension and cataracts make them inappropriate for long-term use.
Lithium carbonate. Lithium carbonate, which is used to treat bipolar disorder, may be effective in preventing chronic cluster headache if other medications haven't prevented cluster headaches.

Side effects include tremor, increased thirst and diarrhea. Your doctor can adjust the dosage to minimize side effects.

While you're taking this medication, your blood will be checked regularly for the development of more-serious side effects, such as kidney damage.
Nerve block. Injecting a numbing agent (anesthetic) and corticosteroid into the area around the occipital nerve, located at the back of your head, may help improve chronic cluster headaches.

An occipital nerve block may be useful for temporary relief until long-term preventive medications take effect.
Ergots. Ergotamine, available as a tablet that you place under your tongue, can be taken before bed to prevent nighttime attacks.

Self-injected dihydroergotamine (D.H.E. 45) also may be helpful. Ergot medications may be effective if taken early in your cluster attacks, but they can't be combined with triptans and can only be used for brief periods of time.
Melatonin. Studies show that 10 milligrams of melatonin taken in the evening might reduce the frequency of cluster headache.

Other preventive medications used for cluster headache include anti-seizure medications such as divalproex (Depakote) and topiramate (Topamax).

SurgeryRarely, doctors may recommend surgery for people with chronic cluster headache who don't find relief with aggressive treatment or who can't tolerate the medications or their side effects.

Surgical procedures for cluster headache attempt to damage the nerve pathways thought to be responsible for pain, most commonly the trigeminal nerve that serves the area behind and around your eye.

However, the long-term benefits of surgery are disputed. Also, because of the possible complications — including muscle weakness in your jaw or sensory loss in certain areas of your face and head — it's rarely considered.

Research in potential cluster headache treatmentsAs scientists learn more about the causes of cluster headache, they're able to develop more-selective treatments for the condition.

Researchers are studying a potential treatment called occipital nerve stimulation. In this procedure, your surgeon implants electrodes in the back of your head and connects them to a small pacemaker-like device (generator). The electrodes send impulses to stimulate the area of the occipital nerve, which may block or relieve your pain signals.

Several small studies of occipital nerve stimulation found that the procedure reduced pain in some people with chronic cluster headaches.

Similar research is underway with deep brain stimulation. In this procedure, doctors implant an electrode in the hypothalamus, the area of your brain associated with the timing of cluster periods. Your surgeon connects the electrode to a generator that changes your brain's electrical impulses and may help relieve your pain.

Deep brain stimulation of the hypothalamus may provide relief for people with severe, chronic cluster headaches that haven't been successfully treated with other medications.

Researchers are studying other types of brain and nerve stimulation to prevent and treat cluster headaches.

The following measures may help you avoid a cluster attack during a cluster cycle:

Stick to a regular sleep schedule. Cluster periods may begin when there are changes in your normal sleep schedule. During a cluster period, follow your usual sleep routine.
Avoid alcohol. Alcohol consumption, including beer and wine, often can quickly trigger a headache during a cluster period.

Because cluster headaches can be so painful, you may be tempted to try alternative or complementary therapies to relieve your pain.

A survey of people with cluster headache who tried a number of alternative therapies — including acupuncture, acupressure, therapeutic touch, chiropractic and homeopathy — found that fewer than 10 percent thought these therapies effective.

Some natural medicines may be worth a try, however. In one study, extract from kudzu, a vine species originally found in Asian countries, was shown to alleviate the intensity, frequency and duration of cluster headache attacks. However, kudzu extract didn't decrease the length of the cluster cycle.

Melatonin also has shown modest effectiveness in treating nighttime attacks.

Living with cluster headache can be very difficult. Cluster headaches can be frightening to you and to your family and friends. The debilitating attacks may seem unbearable.

In addition to the physical symptoms, the chronic pain that often accompanies cluster headache attacks can make you anxious or depressed. Ultimately, it may affect your interaction with friends and family, your productivity at work, and the overall quality of your life.

Talking to a counselor or therapist can help you cope with the effects of cluster headache. Or you may find encouragement and understanding in a headache support group. Although support groups aren't for everyone, they can be good sources of information.

You may also find support groups are a good place for you to share your experiences and hear other group members' experiences. If you're interested, your doctor may be able to recommend a group in your area.

Because the cause of cluster headache is unknown, you can't prevent a first occurrence. However, a preventive strategy is crucial for managing cluster headache because only trying to treat acute attacks with medications can seem hopeless.

Prevention can help reduce the frequency and severity of the cluster attacks and the risk of medication overuse headaches. Preventive medications can also increase the effectiveness of acute medications.

In addition, you may help reduce your risk of future attacks by avoiding alcohol and nicotine, which often cause cluster headaches.