National Headache Foundation Issue 167 HeadLines

MARCH/APRIL 2009 Number 167
  Headaches from Exercise, Sex and Coughing
  National Headache Awareness Week
  Win a New Car
  Environmental Triggers and Headache
  Kids Korner: Post-Concussion Headaches in Young Athletes
  Case Study: Headaches with Sexual Activity
  Readers’ Mail
  Educational Materials 
  Thank You to Our Recent Donors
  Become an NHF member

By Edmund Messina, MD, Medical Director
Michigan Headache Clinic, East Lansing, Michigan

Patients often ask me, “Is exercise good for my headaches?” However, quite a few ask the reverse: “Is it dangerous if my headaches get worse when I exercise?”

It’s common knowledge that exercise is good for us in general. People who regularly exercise will sleep better, feel better and commonly report an overall reduction in their headache frequency. This is puzzling for people who experience a worsening of their headaches when they exercise. And some people actually get a headache when they exercise or exert themselves. It’s helpful to separate this issue into several categories.

Worsening an Existing Headache with Exertion

Most people who get migraine headaches have experienced an increase in head pain when they exerted themselves, such as when running up a flight of stairs or even bending down to look under the bed. Although it is very common for migraine to be exacerbated by exertion, it’s important to note that headaches will also worsen in people with increased pressure inside of their head, including people with brain tumors or blood vessel abnormalities.

Blood vessel abnormalities, such as cerebral aneurysms or arteriovenous malformations (AVM), can be quite dangerous. Please don’t panic if you experience worsening head pain with exertion, but do mention it to your healthcare provider.

Sudden Onset Headaches, With or Without Exertion

Headaches that occur suddenly (reaching peak intensity within minutes or less) need to be evaluated to rule out aneurysms, AVMs and tumors. Aneurysms are bulging areas in an artery and can look like a berry on a stem. A ruptured aneurysm can cause a lethal bleed around the brain. This is known as a subarachnoid hemorrhage. Aneurysms may be missed on a conventional MRI scan or CT scan, but they can usually be found on an MRA (magnetic resonance angiogram). An AVM is a tangle of blood vessels that can bleed and be potentially life-threatening.

One form of sudden headache is called thunderclap headache and is a very dangerous sign until proven innocent. Usually it’s described as “the worst headache of my life” and reaches its maximum pain in less than a minute. A person who gets a thunderclap headache should be evaluated immediately in an emergency room—an emergency CT scan should be done and a lumbar puncture be performed in order to examine the spinal fluid for blood.

Thunderclap headache can be caused by a ruptured blood vessel, such as an aneurysm or AVM, but also by other conditions that need to be ruled out. This headache should never be ignored and subsequent testing with MRI and MRA is necessary.

Thunderclap headache can occur spontaneously or be provoked by exertion or coughing. A cause is never found for a substantial number of thunderclap headaches. These are considered to be primary thunderclap headache. However, it should never be assumed that a person has a primary thunderclap headache until a comprehensive diagnostic evaluation rules out other causes.

Headaches Provoked by Exertion

It’s very important to distinguish pre-existing headaches that are worsened by exertion from headaches that are actually caused by exertion. Some conditions triggered by exertion may be harmless, but others could be due to the same dangerous underlying conditions mentioned previously. People with a new onset of exertional headaches generally need evaluation with a good quality MRI and MRA.

Another common cause of exertional headache is known as the Arnold-Chiari malformation, where the cerebellum, located at the back of the brain, appears to be forced downward through the opening at the bottom of the skull. Remember, if you experience a new onset of exertional headache, you need to be evaluated by your healthcare provider.

Fortunately, most exertional headaches have less frightening explanations. The more benign causes of exertional headache include primary cough headache, primary exertional headache and primary headache associated with sexual activity, which can only be diagnosed once more serious causes are ruled out.

Primary cough headache generally occurs within seconds of coughing, sneezing or straining. The pain is usually described as “sharp,” “stabbing” or “splitting” and can be quite severe in some cases. It usually occurs on both sides of the head and is felt most intensely in the back or top of the head or forehead, although it can also occur in both temples at the same time. The attacks typically last up to one half hour, though some have been known to linger for hours. Cough headaches are not accompanied by any other neurological symptoms and there is no nausea or vomiting.

Cough headache usually strikes people over the age of 40. When it occurs in younger people, evaluation for other causes is especially important. Conditions that imitate primary cough headache include masses in the back of the brain, such as tumors or the Chiari malformation. About half of all cough headache cases are due to an abnormality, so proper testing is very important.

Most people don’t need to treat cough headaches unless they’re having frequent bouts of coughing. The headaches can be prevented by using indomethacin, which may be particularly useful during bouts of bronchitis or other temporary periods of repetitive coughing. Chronic use of indomethacin can produce gastrointestinal bleeding, so caution is needed. Prolonged coughing needs to be evaluated by a healthcare provider and smokers need to stop smoking, permanently.

Primary exertional headache is produced by physical exercise or strain and usually starts as a throbbing pain on both sides of the head. Exertion can take the form of prolonged exercise, strenuous exercise such as lifting weights, or other activities that can cause facial redness. The headaches may occur more readily in high temperatures or high humidity, at high altitude, or after drinking caffeine or alcohol.

About 10% of the general population may experience exertional headaches. Some people experience them immediately upon exertion, others will have to run a few blocks or do a few repetitions of exercise before they strike. Sometimes the headache doesn’t occur until after the exertion. The attacks can last from 5 minutes to 24 hours and usually are bilateral.

Taking medications such as propranolol and indomethacin before exercise can sometimes prevent exertional headaches. Propranolol, however, may reduce a person’s exercise tolerance because it can slow down the pulse, keeping the heart from beating fast when needed. Again, it is essential to rule out other disorders, especially if the headaches are one sided.

Headache associated with sexual activity is more common in men than women, and patients are often embarrassed to tell their doctors about them. Needless to say, they can have a long-lasting impact on a person’s sex drive … so don’t be shy.

Sexually-related headaches can take several forms. Pre-orgasmic headaches often begin as a dull, two-sided headache, which increases with sexual excitement. Orgasmic headache begins abruptly at the moment of orgasm and is usually described as excruciatingly severe and throbbing, and is sometimes associated with nausea and vomiting. People can experience the dull form only, the explosive form only, or both, although the orgasmic headache accounts for about 75% of cases. (Read a case study about a patient with orgasmic headache on page 7.)

Only about half of patients with sexually-related headache have pre-existing migraine. The new onset of this headache, especially if it’s a thunderclap headache, requires immediate evaluation for the causes previously noted. If no obvious underlying cause is identified, this is a benign condition that can sometimes be prevented by using anti-inflammatory medicines before engaging in sexual activity. Over time, this type of headache will occur less frequently.

A less common type of sexually-related headache (perhaps about 5% of cases), is the so-called postural type—after it begins it worsens with standing or sitting up and is relieved by lying down. The postural form is not classified with the primary sexual headaches as it seems to be related to spinal fluid leaks. These leaks, which can be difficult to find, are not dangerous nor are the headaches. The leaks can sometimes be repaired by surgery or by injecting a “blood patch” around the spinal canal.

In summary, existing headaches, especially migraine, often worsen with exertion and this is not usually cause for concern. However, if a pre-existing headache pattern becomes sensitive to exertion or if you experience a new headache brought on by exertion, it’s time for a medical evaluation.


This year’s theme for the National Headache Foundation’s National Headache Awareness Week (NHAW) is Chart Your Course to Headache Relief. We encourage your participation in the 16th annual commemorative week bringing attention to the nationwide problem of headache.

NHAW’s three major goals are to:

  • Gain recognition of headache pain as a real and legitimate condition,
  • Encourage sufferers to recognize their headache pattern and seek information either through a healthcare provider or NHF resources, and
  • Let sufferers know there are a variety of ways to care for headaches.

The focus for the week — and the entire year — is that headaches are personal. People with headache should make a real effort to learn more about themselves and their needs for headache care.

Throughout the week, the NHF will be unveiling a new patient education program called Headache U: It’s All About You. The program will include a questionnaire that will guide headache sufferers toward the help they need and give them tools to “chart” their headaches.

You can get involved in NHAW by organizing, participating or sponsoring headache-related activities in your area. Past volunteers have hosted headache screening days, organized public education programs to discuss headache causes and treatments, worked with radio stations to speak about headache, contacted local newspapers to do stories on the theme or passed out free literature.

The NHF is happy to assist with your program and include your event in the master calendar of activities sent to media nationwide. We can also provide posters and educational materials to help make every event a success.

Visit the NHF Web site at to fill out the activity listing form and materials order form. You can also call the NHF at 1-888-NHF-5552 to obtain forms or get questions answered.

Donations in support of National Headache Awareness Week are also needed. To contribute, click the DONATE button on the NHF home page at

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Can headache sufferers actually predict the weather? According to a recent online survey by the National Headache Foundation, headache sufferers may have a knack for anticipating fickle spring weather—69% of respondents reported weather or barometric pressure changes triggered their headache. While their predictions may or may not be accurate, the survey did accurately report the impact of headache on sufferers’ lifestyle choices due to environmental circumstances—35% of headache sufferers have restricted travel and 75% have been unable to participate in outdoor activities due to headaches caused by environmental triggers such as changes in altitude, weather and high winds.

Most headache sufferers have learned from experience how certain environmental factors play a role in triggering their headaches. While factors like weather and altitude are well beyond human control, the good news is that people do have control over other environmental headache triggers. Considerate co-workers may want to think twice before liberally applying their daily dose of perfume—64% of respondents reported that intense odors were a headache trigger. As a result, 60% stopped wearing perfume or keep clear of the fragrance department in stores in order to avoid a potential headache.

Additional NHF survey results:

  • 56% reported headaches triggered by bright or flickering lights
  • 40% limit their computer use to avoid headaches
  • 40% reported headaches triggered by loud noises
  • 53% avoid loud music concerts due to headaches
  • 33% reported headaches associated with mold allergies

The increasing popularity of smoking bans across the country may prove beneficial for the 52% of sufferers who said cigarette, pipe or cigar smoke was an environmental trigger for their headaches. A ban on smoking in traditionally smoke-filled establishments such as restaurants, bars and clubs would favor the 73% of headache sufferers who limit or avoid time spent at such places.

“Understanding how your nervous system responds to different environmental factors that can trigger your headaches is the first step to prevention,” said Roger Cady, MD, vice president of the NHF.

NHF Tips to Understanding Environmental Headache Triggers:

  • Understand your own sensitivities; be aware of the external influences that you can’t control, such as fluctuations in air pressure and weather, and your reactions to such changes.
  • Be proactive in dealing with factors you can control. Avoid wearing perfume and ask others close to you to be mindful of your sensitivity.
  • If factors like smoke or loud noises trigger your headaches, avoid putting yourself in these types of environments or wear earplugs.
  • Take frequent breaks when using the computer or use a non-glare screen.
  • Get help. Discuss your headaches with your healthcare provider.

Keeping a headache diary can help you figure out what your triggers are. A free, downloadable diary is available from the NHF Web site,, in the Headache Education section.

“Once you identify your personal headache triggers you can take the steps necessary to modify them, such as avoiding irritating smoke exposure by dining at non-smoking restaurants or limiting time spent outdoors on inclement days. In addition, you can employ protective strategies such as biofeedback, exercise or massage at times when you are at risk for headache,” said Cady.

“But if your headaches are out of your control, it is important that you talk to your healthcare provider about other options for prevention and treatment.”


By Joel S. Brenner, MD, Pediatric Sports Medicine and Adolescent Medicine Specialist, Children’s Hospital of The King’s Daughters, Norfolk, Virginia

Parent: My son suffered a concussion during his football game last week and now he’s having a recurring headache.
Doctor: Tell me, what other symptoms is he having?
Parent: He complains of being tired, that sunlight and loud music bother him, and that he has difficulty concentrating in school. He also says the headache gets worse whenever he is trying to do schoolwork, read or watch television. What should we do?

Headaches after a concussion are the most commonly reported symptom and can be debilitating. They are more common in individuals with a history of migraine headaches, but can occur in those without any previous history of headaches.

Patients with post-concussion headaches often describe the pain as a “pressure” or a “pulsating” feeling. The pain is often felt in the same place on the head where the impact took place, but is usually in the forehead or side of the head. The headache is often accompanied by sensitivity to light and/or sound. In addition, the patient may feel dizzy and nauseated, especially during the headaches. Parents may also notice that their child’s personality is affected, becoming more irritable or short-tempered (more than a typical teenager).

It is common for children with post-concussion headache to complain that the headache gets worse at the end of the school day and while trying to concentrate in class, read, watch television, work on the computer or even while texting. The headache is often exacerbated by physical activity, such as walking, running or biking. Other factors that can make the headache worse include loud public events (sporting games or concerts), excessive caffeine consumption, driving or drinking alcohol.

Post-concussion headaches can be persistent and take weeks to months (in extreme cases) to completely resolve. Fortunately, most of these headaches resolve spontaneously with rest and minimal pharmacological treatment.

Treating Post-Concussion Headache

Cognitive and physical rest immediately after the injury are extremely important. If the child ignores his symptoms and tries to “tough it out,” it can delay the recovery process. Resting the brain and the body needs to last as long as the headaches and other symptoms occur.

Cognitive rest means the child may need to stay out of school, part- or full-time, if the headache is persistent. As symptoms improve and there are pain-free periods, the child should be allowed to return to school for half days until he can complete the entire school day without developing a headache. Academic accommodations should be put into place with the help of the school’s guidance counselor, teachers and principal, if needed. These accommodations include having extended time for classroom assignments and homework, postponement of quizzes or exams, and prewritten class notes. The child should also be allowed to put his head down in class if he experiences a headache or be allowed to go to the nurse’s office to rest and take a medication.

Physical rest means limiting physical exertion. Walking should be limited to activities of daily living (e.g., going to school). The child should be excused from physical education class and recess and be discouraged from running, dancing, strength training or any other athletic activity during the recovery period. This will not only help with the headache, but will aid in the prevention of “second impact syndrome,” which develops when a second brain injury occurs prior to complete recovery from the first.

The most important “medicine” is sleep. Encouraging a minimum of eight hours of sleep each night can facilitate the recovery process by allowing the brain to heal.

Pharmacological treatments can also be beneficial if used properly. Over-the-counter (OTC) medications such as acetaminophen or naproxen sodium may be helpful if used for a limited period of time, unless otherwise directed by your healthcare provider. Overusing OTCs can lead to “analgesic overuse” headache and actually make the problem worse. Aspirin products should be avoided in children. Prescription medications such as naproxen, amitriptyline or topiramate can be helpful for some patients, but need to be monitored by a healthcare provider.

Post-concussion headaches are common and debilitating. They can last anywhere from a few days to weeks and even months. How long they linger depends on many factors, but the most important is how quickly treatment is begun after injury.


Case Studies in Headache: Headaches with Sexual Activity

By Katherine Margo, MD, Director of Student Programs, University of Pennsylvania School of Medicine, Department of Family Medicine and Community Health, Philadelphia, Pennsylvania


Mario is a 40-year-old man who has had migraines off and on since he was a teenager. He is able to keep them under control with occasional use of headache-specific medication or ibuprofen. He is in a new relationship, however, and has started having severe headaches all over his head as soon as he achieves a climax during sexual intercourse. This has happened several times and it’s quite distressing. He is worried that it might be something “really serious.” It is also interfering with his relationship in that his partner is reluctant to have intercourse for fear of triggering an attack.


One particularly unfortunate trigger for headache is orgasm. No one really knows how common this type of headache is because people are often too embarrassed to talk about it. We do know that headaches that occur with sexual activity are more common in men than in women. They also tend to occur in people with a history of other types of migraines.

There are three basic types of sexual headaches:

  • a dull ache in the head, neck and jaw that intensifies with sexual excitement
  • a sudden and severe headache that occurs with orgasm
  • a headache that occurs with sitting up after intercourse.

The second type—headache with orgasm—is the most common and what Mario was experiencing. These headaches usually start just before or with orgasm, are very intense and can be quite alarming. They are usually felt on both sides of the head or in the back of the head and tend to be of short duration (up to about 30 minutes, though a duller headache can last up to four hours). While they can last longer than three hours, it’s usually due to an underlying cause. These headaches can occur only once or in clusters over weeks to months, but most people who have them once have them again.

Like migraines, they can be associated with nausea, vomiting and sensitivity to light. They are also similar to exertional headaches, which happen with coughing or exercise. In fact, about 40% of people with sexual headaches have a form of exertional headache as well.

At this point, we don’t know what causes most of these headaches. Rarely, they are caused by a brain hemorrhage, so a medical evaluation should be done after the first occurrence to ensure that there is no serious cause. Once it has been determined that there is no underlying problem, reassurance goes a long way to helping these patients cope.

Unfortunately, there is no one clear medical treatment for most sexual headaches so patients need to experiment to find what works best for them. Some people get relief from indomethacin or similar medications taken 30 to 60 minutes before intercourse. Anti-migraine medications can sometimes help as well. Preventive treatments such as amitriptyline and propranolol, and blood pressure medications like verapamil can be very useful. Taking a nonsteroidal anti-inflammatory medication like ibuprofen before intercourse does not seem to help much, but ergotamine-containing medications taken that way have been shown to help with the headache pain. Triptans, particularly the shorter acting forms (rizatriptan or eletriptan) may be useful as well, though studies have not been done to determine their effectiveness for sexual headaches.


The good news is that sexual headaches are generally self-limited or controllable with the medications described above. Mario tried taking indomethacin 30 minutes before sexual activity and found, to his relief, that he had many fewer headaches and the headaches he did have were minor.

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Constant Headache after Motor Vehicle Accident

Q: My husband was in a car accident five years ago and suffered a brain injury and many broken bones. He now suffers with constant chronic headaches which are gradually worsening over time. The doctors said all his injuries have healed and CT and MRI scans showed Ònothing significant to cause headache.Ó All kinds of therapies and pain medications have been tried, which either did nothing or made his condition worse. The doctors donÕt know why he has a terrible headache all the time.

It seems to me that there should be some kind of testing procedures available that would locate the cause of the headache. And why donÕt the pain medications ease his pain?

A: Morning headaches can be from different origins. Migraine attacks typically start in the morning or wake a person up from sleep. Hypnic headaches also can wake a patient, usually between 1 a.m. and 3 a.m. These last for about one hour and typically occur in people aged 65 and older. Hypertension that is not well controlled may cause morning headaches as well. Salt does not trigger headaches, but too much salt in the diet may be responsible for high blood pressure. You should see your healthcare provider to monitor your blood pressure, especially in morning hours. The pituitary gland, if enlarged due to a tumor, may also cause headache and other symptoms.

George Urban, MD, Diamond Headache Clinic, Chicago, IL

Headache Causing Disability Probably Not Tension

Q: I am under the care of my doctor for headaches. After reading about tension-type headaches, I feel like these are what I have been having. I have mild-to-moderate headaches for two weeks at a time. No over-the-counter (OTC) medicine helps. My doctor gave me a sample of migraine medications, but they didn’t help. I don’t know what to do from here or how to get treatment. Exactly what should I tell my doctor so that he can help me? Do you have any advice to help prevent the headaches? I work full time and I’m a wife and mother to two kids. I can’t continue having these headaches.

A: Unfortunately, headaches are a common symptom following head injury. The headaches may occur regardless of whether the head injury was mild or severe. Headaches that persist for greater than three months following the head injury are called chronic post-traumatic headaches. Although these headaches may occur in isolation, they are often part of the post-traumatic syndrome, which consists of headaches, personality changes and difficulty with concentration, nervousness and sleeping.

The diagnosis of post-traumatic headache is made by considering the timing with which the headache began in relation to the head injury. With severe head injury, diagnostic tests such as MRI of the brain may be abnormal. Often, however, diagnostic tests are normal, especially if the head injury was mild. Recent research has suggested that injury caused by mild traumatic brain injury cannot be seen by typical diagnostic tests in many cases. Tests used in research studies can sometimes detect changes in brain structure that are very small in size, as well as abnormalities in brain function.

The treatment of chronic post-traumatic headaches is often difficult. The best approach includes a combination of therapies involving medications, physical therapy, biobehavioral therapy and cognitive therapy.

Todd Schwedt, MD, Washington University Headache Center, St. Louis, MO

Electric Shocks from Occipital Neuralgia

Q: My 23-year-old son has been suffering from electric shocks and other symptoms of occipital neuralgia. His life has been a living hell as his doctor only told him that he must deal with his Òanxiety.Ó Finally his dentist referred him to a neurologist who diagnosed him with this condition.

Is there anything I should be aware of at this point? I do not want him to go on suffering as he has already been sick for eleven months.

A: Vertigo or dizziness is a symptom that can occur by itself or in association with migraine and can occur even in the absence of headache. It is thought to be a variant of migraine. Treatment is symptomatic relief using medications and rest. Spells of labyrinthitis (inflammation in the inner ear) can occur without any triggers and can last for days to weeks. Most important is to rule out any other causes. If the symptoms persist for a couple of weeks, and particularly if the symptoms are getting worse, seek evaluation (usually from an Ear, Nose and Throat specialist). Treatment typically involves use of medications, like meclizine, and possibly some specific head and neck exercises.

J. W. Banks, MD, Ryan Headache Center, St. Louis, MO

Headache Began Suddenly and Hasn’t Gone Away

Q: My wife has been suffering from a new daily persistent headache since January 1, 2008. At least, this is the latest diagnosis; she was first diagnosed with hemicrania continua. The headache began when she was washing dishes. Suddenly, she suffered a pain like an ice pick poking through her right eye. Since then, she has spent time in the hospital, undergone numerous CT scans and pretty much any other test you can imagine. She has also tried all of the popular migraine medicines and some not so popular. Basically, none of the doctors have known what to do.

A: Occipital neuralgia manifests as intermittent stabbing pains located at the back of the head (the occiput). Although the stabs of pain are short-lived, some people have a constant aching pain that persists between the stabs. There is tenderness and/or triggering of pain when pressure is placed on a specific area between the base of the skull and neck. This spot is where the occipital nerve is closest to the skin. Some people with occipital neuralgia find it painful to touch this area and may avoid activities like laying the back of their head on a pillow.

Although occipital neuralgia is a diagnosis that is often made by considering headache symptoms and examination findings alone, formal diagnosis is made if the pain is relieved after injecting numbing medication (and sometimes steroids) over the occipital nerve. Pain relief of any duration is suggestive of occipital neuralgia. Although this relief may occasionally persist after the injection, usually the relief is short-lived.

An experienced healthcare provider can help to differentiate occipital neuralgia from other headache syndromes that may cause similar symptoms. Occasionally, symptoms fitting the description of occipital neuralgia can be caused by an underlying problem in the head or neck. In fact, headaches caused by problems in the neck (called cervicogenic headaches) can be difficult to differentiate from occipital neuralgia unless a proper examination and sometimes additional tests (such as cervical spine imaging) are performed.

There are several therapies available that are helpful for the treatment of occipital neuralgia. These include oral medications as well as local therapies such as injections. In patients with a muscular cause of occipital head pain, physical therapy may also be of use.

Todd Schwedt, MD, Washington University Headache Center St. Louis, MO

Struggling with Chronic Paroxysmal Hemicrania

Q: I was officially diagnosed with chronic paroxysmal hemicrania in 2007 and indomethacin relieved the pain. However, I also have ulcerative colitis and I had to stop the indomethacin within a year because it was too hard on my gastrointestinal system. My hemicrania headaches are becoming severe and are truly affecting my life, but I have been told that indomethacin is the only remedy for this condition. I need help before I start to literally pull my hair out.

A: Chronic paroxysmal hemicrania is an unusual headache disorder, more common in women and characterized by multiple attacks (generally from 10 to 20) of sharp pain, often around the eyes, lasting just minutes. They are always on one side and often accompanied by redness of the eye, tearing, runny nose and sometimes a change in pupil size or lowered eyelid.

Relief of the symptoms with indomethacin is universal, but your ulcerative colitis no longer allows you to benefit from this drug. Indomethacin is also available in a suppository form, but unfortunately this is probably not an option for you either. However, there is evidence that other classes of medications can be helpful. Some individuals have responded to sumatriptan. Cortico-steroids also help some patients, although long-term and frequent use of this medication is not recommended. I would suggest asking your neurologist about preventive therapies such as topiramate, gabapentin or pregabalin, which are safe for long-term use.

Tarvez Tucker, MD, University of Kentucky College of Medicine, Lexington, KY

Unusual Headache May Be Hypnic Headache

Q: I am an 82-year old male, in relatively good health, who has had occasional ocular migraines (15-20 minute auras without headache) over the past six years. I also get occasional sinus and tension headaches, but last night and this morning I had an unusual headache for the first time. It was on the right side of my head, above the ear, and was characterized by a pulse of pain every five seconds with a lessening of pain in between. I was faintly aware of it during the night, but much more when I awakened at 6 a.m. Its intensity slowly diminished (after some aspirin) four to five hours later.

A: Sometimes patients with migraine can have other headache types that appear later in life. Auras without headache are usually more common as one gets older.

Also, hypnic headache syndrome is a rare headache disorder that has an average age of onset of 66 years old. It is usually a two-sided (but can be one-sided) headache that lasts from 15 minutes to an hour at a time, resolving in no longer than six hours. The headache can recur up to three times a night, often during rapid-eye movement (REM) sleep. It begins abruptly, is throbbing, and usually localized in the front of the head, but occasionally affects the sides of the head or the entire head. There is no associated tearing of the eyes, droopiness of the eyelids or nasal congestion. Rarely, nausea and vomiting may occur.

Hypnic headaches tend to occur at a consistent time, usually between 1 a.m. and 3 a.m. In order for the headache pattern to meet the criteria for hypnic headache, it needs to occur for at least 15 times a month for a minimum of one month. So, if this headache pattern continues during the nighttime, it would be advisable to see a headache specialist or a neurologist.

George Nissan, DO, Diamond Headache Clinic, Chicago, IL

(To find a headache specialist in your area, check out the NHF’s Physician Finder on our Web site, The one-step search will help you locate a specialist in your area. The NHF also has free lists of physician members for most states. Call 1-888-NHF-5552 to get a copy.)

What Is Acute Cephalgia?

Q: What is the difference between migraine headache and acute cephalgia? Which one is worse?

A: Acute cephalgia is the technical term for headache, but it does not specify a cause. Migraine is a specific kind of headache characterized by two out of four of the following characteristics: throbbing, unilateral (one sided), moderate-to-severe pain that is worse with movement, and one out of two associated symptoms: sensitivity to light and sound, or nausea and/or vomiting.

Acute cephalgia can be due to migraine, but it can also be due to something as simple as sinusitis or as severe as a ruptured aneurysm. There are many causes of acute cephalgia that could be better or worse than a migraine. Migraine is just one cause of acute cephalgia.

Susan M. Rubin, MD, Women’s Neurology Center at Glenbrook Hospital, Glenview, IL


National Headache Foundation

Mission Statement
The NHF exists to enhance the healthcare of headache sufferers. It is a source of help to sufferers’ families, physicians who treat headache sufferers, allied healthcare professionals and to the public. The NHF accomplishes its mission by providing educational and informational resources, supporting
headache research and advocating for the understanding of headache as a legitimate neurobiological disease.

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16-page step-by-step instructions for relaxation methods such as meditation, deep-breathing & visualization.
How to Talk to Your Healthcare Provider About Headaches
8-page brochure on when to seek help for a headache problem, keeping a diary, & working with a doctor.
Alternative Therapies & Headache Care
20-page guide to the vast array of alternative headache remedies & methods. Recipient of a Silver Award from the National Health Information Awards.
New Perspectives On Caffeine And Headache: Straight Talk For Headache Sufferers
20-page brochure summarizes and explains the most recent information about the unique relationship between caffeine and headache.
Keeping Track of Your Migraine Patient Diary
36-page logbook has detailed calendars to keep track of headaches & associated symptoms.
Women & Migraine
16-page brochure offers facts, tips and coping strategies for women suffering from migraine in all phases of life from pregnancy to menopause.
Talking to Your Headache Doctor
12-page guide to enhancing communication with your doctor to get the best information & help in developing an effective treatment plan.
A Patient’s Guide to Headaches
16-page brochure on types of headache, with a focus on migraine including dietary triggers, the phases of migraine, medications, & alternative treatments.
A Patient’s Guide to Migraine Prevention & Treatment
18-page guide includes causes and phases of migraine, drug and non-drug approaches to treatment and prevention, and a diet for migraine sufferers.
NEW ITEM - A Patient Guide to Menstrual Headache
16-page brochure offers facts, tips and coping strategies for women suffering from menstrual migraine.

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