If one searched for an experience shared by nearly everyone, headaches would be an unpleasant standout candidate. Indeed, the government declares headaches “the most common form of pain” in the country and a major reason for missed work and clinic appointments.

However, headaches vary greatly in intensity and complexity, as do the approaches to treating them. The most serious, such as migraines, can be severely disabling and costly. To gain more insight into the nature of headaches, UCHealth Today spoke with Dr. Danielle Wilhour, an assistant professor of Neurology and headache specialist with the University of Colorado School of Medicine who practices at the UCHealth Neurosciences Center – Anschutz Medical Campus. Dr. Wilhour is also director of the University of Colorado Headache Medicine Fellowship.

Is there a clinical description for the general term ‘headache?’

“We define ‘headache’ as any type of painful sensation in the head,” Wilhour said. “There are many different types.”

What types of headaches are there?

The two main headache categories are primary and secondary, Wilhour explained. Primary headache pain is due to the headache itself, not an external cause. Migraines, cluster and tension headaches are examples.

Pain from secondary headaches comes from an underlying condition, such as dehydration, infection, high blood pressure, meningitis, aneurysms, brain tumors and blood clots, and artery tears in the neck or head, Wilhour said.

“Luckily, the vast majority of headaches are primary,” she added. “But as health care providers, our job is to evaluate and rule out the secondary causes and more serious conditions.”

What are some factors that frequently contribute to people having headaches?

Genetics can play a role. For example, scores of genes have been identified that predispose individuals to migraines, Wilhour said. “I tell patients that if one of their parents has migraines, there is a 50% risk that their child will have it. If both parents have migraines, there is a 75% chance their child will have it.”

Injuries, including concussions and traumatic brain injury, can also increase the risk of headaches, Wilhour noted. Stress, too much or too little sleep, skipping meals, drinking alcohol or caffeine, hormone changes, abrupt shifts in the weather and physical activity can also “trigger” headaches.

Does diet play a role in headaches?

It can. For example, foods processed with additives like nitrates and monosodium glutamate (MSG) can flip the headache switch, Wilhour said.

“In general, I counsel people to eat a natural diet as much as possible, with foods that include fruits and vegetables, whole grains, lean protein, and healthy fats.” People should also be aware that gluten and dairy sensitivities can lead to headaches, she noted.

When should I become concerned about the frequency of my headaches and seek medical help?

“If you are having more than one or two headaches a week, it’s reasonable to see a health care provider,” Wilhour said. Individuals should also seek help for headaches that are unusually severe or disabling, produce nausea and vomiting, or don’t respond to over-the-counter medications. In addition, changes in vision, loss of sight, and numbness or weakness on one side of the body lasting minutes to an hour – called an “aura” – can be signs of migraine.

Most seriously, “thunderclap” headaches, which suddenly cause severe pain, may be caused by a brain aneurysm, blood clot or hemorrhage. “The pain level in these headaches can go from zero to 10 within seconds,” Wilhour said. They require emergency care as soon as possible,

How does the CU Headache/Pain Medicine Clinic diagnose headaches?

Wilhour said providers gather as much information as possible from patients and use it to tailor their care. The steps include:

• Discussing the patient’s headache history and how it has evolved.
• Reviewing medications and how the patient responded.
• Screening for more serious conditions.
• Evaluating and addressing comorbid diseases, such as cancer.
• Recommending imaging, referral to other specialists, and other additional tests, if necessary.
• Offering procedures such as nerve blocks and trigger point injections.
• Making an individualized treatment plan that may include prescription medications and vitamins.

“I also ask if the headache is positional in nature,” Wilhour noted. “Is it worse standing up or lying down?” The changes in either case may point to too much or too little fluid in the sac that protects the brain and spinal cord.

Migraines, cluster headaches and tension headaches have unique symptoms that the clinic also evaluates in making a diagnosis.

Let’s talk first about migraines. What are they, and how are they different from other headaches?

“Migraines are often misconstrued as just another headache,” Wilhour said. “In fact, they are a complex neurological disease that often involves severe light and sound sensitivity, as well as nausea and vomiting. They can last from four hours up to three days with moderate to severe intensity.” Migraines generally produce throbbing pain on one side of the head, she added.

How common are migraines?

Migraine is the most common neurological disease in the world, Wilhour said, with about one in four people having “some sort of ongoing or prior migraine history.” Migraine is also the second-most disabling disease globally. “It has a high toll rate, with peaks in people’s 30s and 40s, the prime of life,” she said.

“Many people think that a mild or tolerable headache is the same as a migraine, but that discounts the disabling features and impacts that a migraine can have on quality of life,” Wilhour added. “In addition to the pain of migraines, there is also an element of stigma. We need to let people know how many individuals are affected and increase awareness of the disease.”

Are some people at greater risk for migraines?

Yes. They are three times more common in women than in men, most likely because of post-puberty hormonal changes, Wilhour said. American Indians and Alaskan Natives have the highest prevalence of migraines among ethnic groups, but there are also disparities in diagnosis and treatment for Black and Latino people.

What do we know about the causes of migraines?

The primary culprit is the trigeminal nerve, a major component of the body’s pain pathway, Wilhour said. Changes in the brainstem activate the nerve and signal it to release inflammatory substances, most notably CGRP (calcitonin gene-related peptide), that swell blood vessels and generate pain. As noted earlier, genetics are an important risk factor for migraines.

How are migraines treated?

The first-line treatments are over-the-counter medications, like Tylenol and ibuprofen, and caffeine, Wilhour said. Prescription medicines such as triptans can also stop a migraine. Blood pressure, anti-depressant and anti-seizure medications can help prevent migraine attacks. These medications include topiramate and propranolol, which Wilhour said have demonstrated their effectiveness. Botox injections are also approved to treat chronic migraines (15 or more days a month).

FDA-approved “neuromodulation devices” are another migraine treatment. They use electrical stimulation to head off attacks. These include Cefaly, which fits around the head and sends electrical impulses that both stimulate and calm the trigeminal nerve. The Nerivio device is worn on the arm. It electrically signals the brainstem to fire pain-blocking neurotransmitters.

More recent medications treat migraines specifically, Wilhour said. They target the migraine-triggering CGRP molecule. These medications include:

• Aimovig, Emgality and Ajovy. These are injectable medications.
• Vyepti, delivered by infusion.
• Nurtec, Ubrelvy and Qulipta. These oral medications are CGRP “antagonists,” Wilhour said. They prevent pain by blocking the nerve receptors for the molecule.

Wilhour noted that Nurtec is the only medication approved to both prevent and stop migraines after they occur. Qulipta can be taken daily.

How effective are the new medications?

Very, Wilhour said. “We look for a 50% success rate. These new ones can reach 75% to 100%. That’s remarkable compared to the older medications.”

Are there drawbacks?

Wilhour said the side effects are generally mild. However, they are expensive, and patients will usually need to try more established medications before getting approved for the new ones.

What are cluster headaches?

These are rare headaches that affect only about one in one thousand people. Men are more than twice as likely to be affected. However, cluster headaches can be severely debilitating for sufferers, Wilhour said.

“Cluster headaches are considered one of the most painful conditions experienced by mankind,” she said. They occur in “cyclical patterns,” sometimes seasonally, and can last from several weeks to months. Patients can experience up to eight attacks a day, Wilhour added.

What are the symptoms of cluster headaches?

Unlike migraine headaches, cluster headaches generally do not have triggers. They often generate stabbing pain over or behind one eye and can radiate to other areas of the face. They may also cause swelling and drooping around the eyes and changes in the pupils. The attacks, which may occur during the night, have been compared to “an ice pick to the head,” Wilhour said.

Feelings of restlessness and agitation may warn of a looming cluster headache attack, she added. The cyclical assaults can be followed by periods of remission, then another round of headaches.

What causes cluster headaches?

There is a correlation with head trauma and tobacco and alcohol use, Wilhour said. Changes in the hypothalamus, the part of the brain that helps to manage our sleep and sense of time, are probably also involved in cluster headaches, she noted.

What are the treatments for cluster headaches?

“I try to get people on preventive medicines to end the cycle sooner,” Wilhour said. She cited verapamil, a blood pressure medication, as an example. Short treatments of high-flow oxygen have been effective in ending an attack, as have nasal sprays, such as zolmitriptan.

More recently, the migraine injection treatment Emgality received FDA approval to decrease the frequency of cluster headaches.

Are there self-management techniques and/or lifestyle changes I can make to reduce my risk of headaches or lessen their effects?

Yes. “Lifestyle measures in general have a modest protective effect if they are done consistently,” Wilhour said. She highlighted several:

• Drink 64 to 96 ounces of water daily.
• Perform 30 minutes of moderate aerobic exercise four times a week.
• Do not skip meals.
• Limit caffeine intake.
• Get 7 to 8 hours of sleep a night.
• Limit stress with techniques like mindfulness, yoga and meditation.

Can I get help in managing the stress of headaches?

Yes. Wilhour said she collaborates with psychologists and psychiatrists, who can help patients manage their stress and cope with the pain and unpredictability of headaches.

“Patients may experience the fear of not knowing when an attack is going to happen,” she said. “That can be an important component of treatment.”

Talking about stress also brings up tension headaches. What are they?

Tension headaches are very common. They often occur because of stressful mental and physical environments and our reactions to them, Wilhour said.

“A lot of people don’t realize when they are stressed that they hunch their shoulders and clench their teeth,” she noted. People can ease tension by consciously improving posture and, as noted above, developing relaxation techniques. Physical therapy and massage can also reduce stress and the risk of tension headaches, she said.

Does the CU Headache/Pain Medicine Clinic collaborate with other specialists?

Yes. In addition to the previously mentioned psychology and psychiatry, the clinic refers headache patients to other providers for specialized help, including:

• Interventional Pain
• Physical Therapy
• Ophthalmology and Neuro-Ophthalmology
• Dentistry
• Sleep Medicine
• Integrative Medicine
• Neuroradiology
• Ear, Nose and Throat
• Neurosurgery

What is the importance of the University of Colorado Headache Medicine Fellowship program? 

Wilhour noted that an American Headache Society study estimated that an additional 3,700 headache medicine specialists are needed to care for migraine sufferers, with the gap expected to grow to 4,500 by 2040.

“The shortage of headache specialists nationwide means that it is so important that we train fellows who in the future are going to know the cutting-edge treatments and options that we have,” Wilhour said. “We need to expand access for patients, keep them out of the emergency department and give them options other than narcotics for treatment.”