Headaches: Why You Get Them and What You Can Do About Them

Table of Contents

• Key Points
• Introduction: The Headache Problem
• Understanding Migraine: The Most Common Culprit
• Do I Have a Brain Tumor? Understanding the Real Risk
• Brain Swelling and Pressure: How the Skull's "No-Give" Design Causes Pain
• The Meninges: The Pain-Sensitive Membranes
• Imaging the Brain: CT vs. MRI
• Headaches in Children: A Special Concern
• Headaches in the Elderly: Three Conditions to Watch
• Tension Headaches and "Sinus" Headaches: The Migraine Connection
• Clinical Implications: What This Means for Patients
• Limitations: What This Review Couldn't Prove
• Recommendations: Actionable Advice for Patients
• Frequently Asked Questions
• Source Information

Key Points

• Approximately 20% of people have at least one intense headache each year; most intense headaches are migraine, not brain tumors.
• Migraine is genetic, inherited, and cannot be cured; management, not cure, is the realistic goal.
• Red flags requiring urgent care: thunderclap headache, headache with fever and neck stiffness, and nighttime headaches in children.
• MRI is the preferred imaging for the brain tumor question because it provides detailed images without radiation.
• In elderly patients with new headaches, subdural hematoma, temporal arteritis, and ophthalmic zoster should be evaluated promptly.

Introduction: The Headache Problem

Headaches are so universal that anyone who claims never to have had one probably has a poor memory. The numbers are striking: approximately half of the population experiences headaches at least once per month, approximately 15 percent at least once per week, and approximately 5 percent deal with headaches daily. However, how much people suffer from their headaches depends not just on frequency but on intensity—and intensity is the main driver that pushes people to seek medical help.

Fortunately, for most people, headaches are mild enough that nonprescription pain medications—such as aspirin, acetaminophen (also called paracetamol), ibuprofen, or naproxen—fully relieve them. Nearly half of those with daily headaches fall into this "fortunate" category. The other half, however, have daily headaches with migraine headaches superimposed upon them, and those require more specialized treatment.

Headache pain can also be caused by conditions unrelated to the brain that affect the whole body. These include high blood pressure (hypertension), a shortage of red blood cells (anemia), and low thyroid function (hypothyroidism). These conditions can also make migraine worse, and when they cause intense headaches, it's because the person already carries a genetically determined migraine vulnerability.

Understanding Migraine: The Most Common Culprit

Migraine is by far the most common reason people experience headaches that aren't relieved by a couple of aspirin. Approximately 20 percent of the population—one out of every five people—has at least one such intense headache in the course of a year. Migraine is a genetically determined and inherited condition that makes people vulnerable to intense headaches. Because it runs in families, a simple conversation with parents, grandparents, or siblings about headaches that resist ordinary pain relievers can often confirm the pattern. Men especially tend to describe their episodes as "bad tension headaches" or "bad sinus headaches," when in fact, they are experiencing migraine.

The author of this work brings a uniquely deep perspective. He trained in headache management with John R. Graham, MD, MACP, who dedicated more than half a century to studying and treating headaches. Professor Graham, in turn, trained with Harold G. Wolff, MD, widely regarded as the father of headache research. In the first half of the last century, Professor Wolff investigated headache in most of its presentations and causes—much of what we know today about migraine and other headache disorders comes from his work with headache patients.

One important message: headaches, including migraine, cannot currently be cured. As the author notes, the word "medicine" comes from the Latin medicina, whose verb root mederi means "to heal." The field was once accurately called headache management, acknowledging that control, not cure, is the realistic goal. The author criticizes the newer label "headache medicine" as an "inherent promise that we as physicians or other health care practitioners generally cannot fulfill."

Do I Have a Brain Tumor? Understanding the Real Risk

"In all likelihood, you do not," the author states plainly—but it's still an important question to ask, and one that medicine should take seriously, because reassurance is key. It's a valid concern, but brain disease is a rare cause of headaches, especially considering how common headaches are.

The word "tumor" itself causes unnecessary alarm. In medicine, tumor is a general term for swelling, which can result from many causes and doesn't have to be cancer. In the brain, any significant swelling causes headache because the skull is a hard structure that surrounds the brain and does not give. When pressure increases inside this rigid space, it's painful—although generally not terribly so.

The brain itself is insensitive to pain. For a brain condition to cause a headache, it must be big enough to stretch the blood vessels, which are pain-sensitive. This can happen through:

• Generalized swelling of the brain
• Enlargement of the brain's fluid chambers (hydrocephalus)
• A tumor (whether cancer, bleeding, or abscess), due to associated swelling (edema)
• Inflammation from a viral infection (viral encephalitis)

Importantly, diseases of the brain can cause intense headaches, but that's rare without an underlying migraine vulnerability. Modern imaging techniques are excellent at checking the brain's condition, and they're readily available—typically covered by insurance when ordered by a physician or other health care practitioner.

Brain Swelling and Pressure: How the Skull's "No-Give" Design Causes Pain

Swelling can affect just part of the brain or the space between the brain and the skull, but it can also involve the brain as a whole. When the whole brain swells, the condition is called benign intracranial hypertension, better termed idiopathic intracranial hypertension (IIH). It's also known as pseudotumor cerebri, because it presents like a brain tumor when it isn't one.

IIH is most commonly seen in obese young women, and its cause is generally unknown. However, a blood clot in one of the large veins draining blood from the brain can be responsible. Occasionally, the cause is use of tetracycline (an antibiotic) or taking too much vitamin A (an old-fashioned acne treatment). IIH typically causes a persistent, low-grade headache along with impaired vision caused by swelling of the optic discs—the site where the optic nerve enters the back of the eye. Doctors inspect this area through a simple physical examination called fundoscopy.

Since the optic nerve is an extension of the brain, it swells when pressure inside the skull rises. Looking into the eyes and examining the eye grounds is an important, low-tech way to gain reassurance that a brain tumor or anything else increasing skull pressure isn't the cause of the headaches.

The Meninges: The Pain-Sensitive Membranes

Unlike the brain itself, the three membranes surrounding it—collectively called the meninges—are sensitive to pain, just like the brain's blood vessels. The two inner membranes can become inflamed due to a viral, bacterial, or fungal infection, a condition called meningitis. This is a particular concern in young children, teenagers, and adolescents.

Meningitis produces a headache accompanied by fever and a very specific kind of neck stiffness: it becomes difficult to bend the neck forward, while it moves well in every other direction. The same kind of neck stiffness occurs with subarachnoid hemorrhage—bleeding between the two inner membranes—but in that case there's no fever, and the headache has a very acute or peracute onset, "like a blow to the head."

Bleeding can also occur between the two outer membranes, or between the outer membrane (the dura mater) and the skull. When it happens between the dura mater and the skull, it's called an epidural hematoma, and it's always due to a head injury—generally one forceful enough to fracture the skull. When bleeding occurs between the two outer membranes, it's a subdural hematoma. A head injury still causes it, but it's usually mild and easily forgotten.

Subdural hematoma occurs predominantly in the elderly, because age-related brain shrinkage stretches the bridging veins between the brain and skull, making them vulnerable to injury. A mild bump—like knocking the head against an open cabinet door—can make them bleed. Because it's a venous bleed, it's not as catastrophic as the arterial bleed from an aneurysm. It generally causes a persistent, low-grade headache, possibly with memory impairment. If undiagnosed, it can be fatal—yet it's easily detected with imaging and treated with a relatively simple surgical procedure.

The dura mater can also develop tumors, most commonly a benign growth called a meningioma. These grow slowly over years or decades and can present as chronic headache, including migraine without aura. One case vignette describes a 33-year-old woman with seven years of headaches that gradually became almost daily, located in the right forehead without nausea, vomiting, light sensitivity, or noise sensitivity. A CT scan with iodine contrast revealed a right-sided meningioma in the front of her head—and removal of the tumor completely resolved her headaches.

Another vascular abnormality, the arteriovenous malformation (AVM), is a congenital condition present at birth. When it affects the back of the brain where vision is located, it produces visual aura symptoms and migraine with aura. In one striking vignette, a 37-year-old man with headaches since college experienced five headaches in just ten days, each building to maximum intensity in five to ten minutes and lasting six to twelve hours. The pain was an intense pressure on the left side of his forehead and behind the eye; half were severe. He had light sensitivity and occasional nausea and vomiting, plus a visual disturbance of blue spots in his right visual field. Triggers included bright light, overexertion, red wine, monosodium glutamate (MSG), and drinking more than two cups of coffee. MRI revealed a large AVM in the left occipital lobe. Surgery made the malformation smaller but caused permanent vision loss—and unfortunately, his headaches continued unabated.

Imaging the Brain: CT vs. MRI

Computerized tomography (CT) and magnetic resonance imaging (MRI) are the two main ways to visualize the brain. CT is performed without contrast when the headache is acute and the goal is to exclude bleeding. Bleeding can result from head injury, stroke (also called brain attack), or the rupture of an aneurysm—a localized balloon-like expansion of a brain artery.

Rupture of an aneurysm is catastrophic, producing a headache that comes on like a blow to the head. This thunderclap headache is characteristic of subarachnoid hemorrhage and represents a medical emergency: half of those who suffer from it die.

If CT is performed for reasons other than excluding bleeding—such as post-traumatic headache or headache of peracute onset—it should be done with intravenous iodine contrast. This is especially important if a suspected blood vessel abnormality like an AVM is causing the headaches.

MRI is superior to CT for addressing the brain tumor question. When performed for this purpose, it doesn't require intravenous contrast (gadolinium), and unlike brain CT, it involves no radiation. MRI also has better resolution, allowing more detailed examination of the brain, including its blood vessels, the nerves originating from the brain stem, and the surrounding membranes.

Headaches in Children: A Special Concern

In children, brain tumors are often located in the cerebellum—the "small brain" at the back of the head that plays an important role in balance. These tumors grow over weeks or months and ultimately compress the fourth ventricle, the chamber through which cerebrospinal fluid (CSF) emerges from the brain's chamber system. CSF is produced in the lateral ventricles, flows through the brain stem, passes through the third and fourth ventricles, and is absorbed into the blood through veins on top of the brain. When something compresses the fourth ventricle, fluid can't escape, the chambers enlarge, and hydrocephalus develops.

Hydrocephalus causes severe headaches, often with projectile vomiting. These headaches typically happen at night, waking the child from sleep, or are present when the child wakes in the morning. While nighttime headaches in adults are common with nocturnal migraine or cluster headache, in a child, they are an "ominous presentation" that requires expeditious brain visualization—preferably with MRI.

Viral meningitis is sometimes mistaken for migraine, but meningitis is a single episode while migraine recurs over time. Bacterial meningitis is unlikely to be mistaken for migraine because the patient is very sick, with high fever, and may be confused or even delirious. In both circumstances, a spinal tap (lumbar puncture) is needed for proper diagnosis—but never before first imaging the brain with CT or MRI.

Headaches in the Elderly: Three Conditions to Watch

In an older patient with relatively recent onset of headaches, subdural hematoma isn't the only concern. Two other conditions deserve attention: temporal arteritis and ophthalmic zoster.

Temporal arteritis, better termed giant cell arteritis, is an inflammatory disorder of the body's arteries, including those of the head. It causes a persistent, generally low-grade headache, often with fatigue, low-grade fever, and muscle pain—particularly in the jaw muscles during chewing, a symptom called jaw claudication.

Diagnosis begins with blood tests measuring inflammation: the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level. Confirmation requires microscopic examination of a section of the superficial temporal artery—the blood vessel running in the temple. Though the headache may be one-sided, doctors should prudently take sections of both temporal arteries, and those sections need to be relatively long, because inflammation may not affect the entire length.

Blindness and stroke are potential consequences of giant cell arteritis. Treatment requires long-term use of a corticosteroid, which is why solid confirmation of the diagnosis is so essential. Response to treatment is tracked by repeating the blood tests of inflammation.

Ophthalmic zoster is a form of shingles caused by reactivation of the chickenpox virus, which resides in nerve knots called ganglia. The relevant one here is the trigeminal ganglion, located at the base of the skull, with three branches—hence "trigeminal." The ophthalmic branch, the maxillary branch, and the mandibular branch carry sensory information from the forehead, cheek, and jaw to the brain. When the ophthalmic branch is inflamed, pain appears on one side of the forehead. Little blisters develop in the painful area, singly or in small groups, several days after pain begins—sometimes hiding among the eyelashes or in the hairline.

Treatment involves an antiviral medication such as acyclovir or valacyclovir, plus a nerve pain medication like gabapentin or pregabalin. Follow-up with an eye specialist (ophthalmologist) is critical, because the cornea may be affected, and the condition can cause blindness.

Tension Headaches and "Sinus" Headaches: The Migraine Connection

The term "tension-type headache" was introduced by the International Headache Society (IHS) for two reasons. First, studies of muscle activity generally don't demonstrate contraction of head muscles during this kind of headache—though that could be due to studying the wrong muscles, using the wrong technique, or using a technique not sensitive enough to register activity. Second, experts agree that tension or mental stress is not the only cause; a great variety of triggers can be responsible.

The causes of tension headache are "tremendously mundane," making it such a common experience that it seems part of life. Fortunately, these headaches typically don't last more than a couple of hours and are easily relieved by rest, relaxation, or a nonprescription medication.

Yet here's the crucial insight: "Bad tension headaches, bad sinus headaches, and bad hangover headaches do not exist." In the author's experience, they are all migraine headaches, triggered by tension or stress, nose or sinus issues, or alcohol. Approximately half of the population with daily headaches is fortunate enough to find relief with nonprescription pain relievers—the other half has migraine headaches superimposed on their daily pain, requiring medications specifically developed for migraine, not just general pain relievers.

Clinical Implications: What This Means for Patients

For patients, this review offers several key takeaways:

• Reassurance is powerful. The vast majority of headaches, even intense ones, are migraine—not brain tumors or other ominous conditions.
• Migraine is genetic, not psychological. It's an inherited vulnerability that runs in families, which can be confirmed by asking relatives about their own headache patterns.
• Management, not cure, is the goal. Since migraine can't be cured, effective management involves both medication and education about triggers and treatment options.
• Red flags deserve prompt attention. Thunderclap headaches (sudden, like a blow to the head), headaches with fever and neck stiffness, nighttime headaches in children, and recent-onset headaches in the elderly all warrant immediate medical evaluation.
• Simple physical exams matter. Fundoscopy—examining the optic discs—can provide important reassurance without any imaging.
• Imaging is available and covered. MRI is the preferred test for the "brain tumor question," with no radiation and detailed images, while CT plays a specific role in ruling out acute bleeding.

Limitations: What This Review Couldn't Prove

This material is drawn from clinical experience and a historical review of headache research rather than a controlled clinical trial, so it can't provide statistical effect sizes for treatments. The patient vignettes are illustrative case reports, not population data. Additionally, the author notes that many theories about migraine have been advanced over time by people with little clinical experience with migraine patients—sometimes for self-promotion or product sales—which means patients should be skeptical of any treatment claiming to be a universal cure.

The author also acknowledges that the term "headache medicine" implies a promise of healing that can't be kept. Headaches are a complicated problem, and not every patient responds fully to available treatments—as the case of the 37-year-old man with the AVM demonstrates, even successful surgical treatment of an underlying condition doesn't always resolve the headaches.

Recommendations: Actionable Advice for Patients

For patients experiencing headaches, the author's guidance can be summarized as follows:

1. Start with the basics. For typical headaches, nonprescription medications like aspirin, acetaminophen (paracetamol), ibuprofen, or naproxen are often sufficient. About half of daily headache sufferers get full relief from these.
2. Recognize migraine patterns. If your headaches are intense, accompanied by light sensitivity, nausea, or visual disturbances, and don't fully respond to ordinary pain relievers, they may be migraine. Ask your parents, grandparents, and siblings about their headaches—family history is a strong clue.
3. Seek care for intense headaches. Migraine requires medications specifically developed for it, not just general painkillers. These are prescribed by physicians or other health care practitioners trained in headache management.
4. Address whole-body conditions. If you have high blood pressure, anemia, or low thyroid function, treating these properly may improve your headaches and make migraine easier to manage.
5. Get reassurance when worried. If you're concerned about a brain tumor, don't suffer in silence. Imaging tests are readily available and typically covered by insurance. MRI is the preferred test—it gives detailed images without radiation.
6. Seek urgent care for red-flag symptoms. Go to an emergency room if you experience a headache that comes on like a blow to the head, a headache with fever and difficulty bending your neck forward, or severe nighttime headaches in a child.
7. For elderly patients with new headaches. See a doctor promptly. Subdural hematoma, temporal arteritis, and ophthalmic zoster are all treatable, but early diagnosis is essential—especially for temporal arteritis, where blindness and stroke are preventable with prompt corticosteroid treatment.

Frequently Asked Questions

What are the chances that my headache is a brain tumor?

In all likelihood, you do not have a brain tumor. Brain disease is a rare cause of headaches, especially considering how common headaches are. Modern imaging, like MRI, can reassure you. MRI is the preferred test for the brain tumor question because it gives detailed images without radiation.

When should I go to the emergency room for a headache?

Seek urgent care for a headache that comes on like a blow to the head, a headache with fever and difficulty bending your neck forward, or severe nighttime headaches in a child. These red flags may indicate bleeding, meningitis, or hydrocephalus. Also see a doctor promptly for new headaches in an elderly patient.

What is the difference between CT and MRI for headache evaluation?

CT is performed without contrast when the headache is acute and the goal is to exclude bleeding. MRI is superior for the brain tumor question, offers better resolution, and involves no radiation. MRI does not require intravenous contrast when checking for a brain tumor, but CT with contrast is used for suspected blood vessel abnormalities.

Can my family history help diagnose migraine?

Yes. Migraine is a genetically determined and inherited condition that runs in families. Asking your parents, grandparents, or siblings about headaches that resist ordinary pain relievers can often confirm the pattern. For example, men often describe their episodes as bad tension or sinus headaches when they are actually migraine.

What is idiopathic intracranial hypertension and who gets it?

Idiopathic intracranial hypertension (IIH), also called pseudotumor cerebri, is a condition where the whole brain swells, causing persistent low-grade headache and vision problems. It is most commonly seen in obese young women, and the cause is generally unknown. A blood clot, tetracycline, or excess vitamin A can also be responsible.

Why do elderly people get subdural hematoma from mild head bumps?

Age-related brain shrinkage stretches the bridging veins between the brain and skull, making them vulnerable to injury. A mild bump, like knocking the head against an open cabinet door, can make them bleed. This venous bleed causes persistent low-grade headache and possibly memory impairment. It is easily detected with imaging and treated surgically.

What medications work for migraine versus tension headache?

For typical headaches, nonprescription medications like aspirin, acetaminophen, ibuprofen, or naproxen are often sufficient. Migraine requires medications specifically developed for it, not just general pain relievers. About half of daily headache sufferers get full relief from nonprescription drugs; the other half has migraine superimposed on daily pain and needs specialized treatment.

Source Information

This patient-friendly article is based on peer-reviewed research and clinical expertise drawn from the original work: "Headaches: Why You Have Them—What You Can Do About Them", a comprehensive medical text covering the diagnosis and treatment of headache and face pain. The content draws heavily on the author's training with John R. Graham, MD, MACP, and Harold G. Wolff, MD, and on decades of clinical practice managing thousands of headache patients.

Key statistical data referenced includes: approximately 50% of the population with monthly headaches, 15% with weekly headaches, 5% with daily headaches, and 20% of the population (1 in 5 people) experiencing migraine-level intense headaches annually. The vignettes of the 33-year-old woman with meningioma and the 37-year-old man with occipital arteriovenous malformation are drawn directly from the original text.

Note: This article is a patient-friendly translation of the source material and is provided for educational purposes. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition.