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Recently I was up in the middle of the night, on my computer, trying to figure out what could be causing the pounding headache I'd had for five days. Aha! Sinus infection. My doctor confirmed my self-diagnosis the next day and sent me home with nasal spray and a prescription for antibiotics.
"Brain tumor averted," I told my husband.
"I didn't want to say anything, but I was thinking brain tumor, too," he said, clearly as relieved as I was.
It's easy to fear the worst when you have a really bad headache, even though most are benign. But it can also be risky to ignore your symptoms. "A severe headache or changes in your headache pattern can signal a real health emergency," says Dawn Marcus, MD, associate professor at the University of Pittsburgh Medical Center and author of 10 Simple Solutions to Migraines. "Even if you're getting headaches that are mild but unlike any you've had before, bring it up with your doctor." We asked the experts how to tell normal symptoms from warning signs.
1. Your headaches aren't constant -- they go away after a few hours. But they keep coming back.
Possible cause: If you have a dull ache behind your eyes and it hurts just to move your head, you may have a sinus headache caused by allergies or an infection. You probably have a tension headache if it feels more like a vise tightening around your temples, the back of your head, and your neck.
What to do first: Don't try to cure yourself. Instead, see your doctor or allergist and get diagnosed. If you take a decongestant for a sinus headache but it's actually a migraine, the drug could worsen the pain.
Getting treated: For sinus aches your doctor may suggest decongestant, saline, or prescription corticosteroid nasal sprays and either antibiotics (for infection) or antihistamines (for allergies). Tension headache aids include analgesics, antidepressants, and muscle relaxants, as well as icepacks, biofeedback, and yoga.
2. There's a pulsating pain on one side of your head. Light and noise make it worse.
Possible cause: Perhaps a migraine, even if you think you don't get them. Half the people with migraines think they're something else, says a recent national migraine survey. Swollen blood vessels in the brain trigger migraines, which are hereditary. And the pain isn't always intense. "If you remember seeing your mother throw up and stay in bed all day long from a migraine, you may think that anything less severe couldn't possibly be the same thing," says Dr. Marcus. Don't discount your symptoms.
What to do first: Start with an over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as aspirin, ibuprofen, or naproxen. A pill with caffeine (for example, Excedrin) can increase the anti-migraine effect. Sleeping may help, too, as it can alter serotonin levels, which is how some prescription migraine medicines help relieve the pain, Dr. Marcus explains.
Getting treated: Consider going to a headache specialist. You'll probably be asked to keep a diary to see whether certain foods (red wine, caffeine, aged cheese, for instance) or situations (skipping meals, stress, smoke, intense exercise) are prime migraine causes. Hormone changes can also be a factor. Your doctor may prescribe drugs including beta and calcium channel blockers, triptans, and ergotamines. Botox injections can help, perhaps by blocking pain pathways or chemical processes. You can also numb the throbbing area with a Lidoderm patch.
3. You seldom get headaches, but this one's a doozy and you've had it for three days.
Possible cause: It could be a new daily persistent headache, one type of a condition called chronic daily headaches. Suspect NDPH if the pain started abruptly and you're queasy and sensitive to light and noise. Recent illness could be a factor; many sufferers test positive for the Epstein-Barr virus. It could be chronic tension headache if the pain varies in intensity but is continuous, a condition often linked to depression and anxiety. Or you could have a rebound headache from extensive use of pain relievers or migraine drugs. These punishing headaches can happen 15-plus days a month, each lasting four hours or longer.
What to do first: Ask your doctor about stronger drugs or if you should stop taking what you're already using.
Getting treated: NDPH usually gets better by itself, though painkillers may help in the short term. Antiseizure drugs can relieve severe cases. Chronic tension headaches often respond to antidepressants; biofeedback can help, too. Botox injections in the back of the head and neck could relax the muscles that contribute to tension headaches. If drug overuse is the cause, other treatments, including non-drug ones, may break the cycle.
4. Your head hurts all over -- a lot -- and you also have a fever and a very stiff neck.
Possible cause: Meningitis or, less likely, encephalitis. Meningitis is an inflammation of the lining of the brain and spinal cord, while encephalitis is an inflammation of the brain itself. A virus or bacteria can cause either disease, and the bacterial infection is more deadly. If you have meningitis you may also develop a rash.
What to do first: Rush to the ER. "Minutes count, especially for bacterial meningitis," says Merle Diamond, MD, a clinical assistant professor at Rosalind Franklin University of Medicine and Science/Chicago Medical School.
Getting treated: At the ER you'll get a neurological evaluation and spinal tap, says Dr. Diamond. If the cause is bacterial you'll receive intravenous antibiotics. For a viral infection you may be given an antiviral drug; severe cases may require prescription antiseizure drugs and steroids.
5. You bumped your head and have a really bad headache.
Possible cause: As actress Natasha Richardson's March 2009 death showed, even a minor knock to the head can cause a deadly brain injury. Or you could have a concussion, a less-severe but still-serious trauma. "People are surprised when they have really bad headaches after something fairly minor, but if you black out or become confused you need to be checked immediately," says Dr. Marcus. Concussions can cause memory loss, affect balance and coordination, and bring about headaches for weeks or months. Women are more prone than men.
What to do first: Go to the ER. And no matter how much your head hurts, don't take anything with aspirin, ibuprofen, naproxen, or any other NSAID; all these drugs increase your risk of having bleeding in the brain.
Getting treated: If all you have is a concussion, the main cure is rest: Don't do anything mentally taxing or physically risky until you get word from your physician. Your headaches may continue for a while, so ask your doctor which pain-relief medications are safest. But if a CAT scan reveals bleeding in your brain, you may need surgery (to handle swelling or repair broken blood vessels), medications for seizures, and physical or speech therapy.
6. You have a sudden, intense, excruciating headache. After several minutes the pain begins to fade.
Possible cause: "Thunderclap" headaches can signal a subarachnoid hemorrhage, when a brain artery with a weakened wall (aneurysm) ruptures or is about to. These strokes are rare but can happen as early as your 20s. It's very abrupt and feels like the worst headache of your life, says Stephen D. Silberstein, MD, director of the Headache Center at Jefferson Medical College of Thomas Jefferson University. Other signs? Loss of consciousness, nausea, and a stiff neck.
If tests rule out a stroke, you may have had a cluster headache. These start with excruciating pain, often behind the eyes. You can get as many as four a day for several weeks. Then they disappear for months or forever.
What to do first: As with a head injury, don't take aspirin or any other NSAID, which will make any bleeding worse. Instead, go to the ER immediately, even if the headache stops.
Getting treated: First you need a CAT scan and maybe a spinal tap to see if you had a stroke. If so, surgery and medications may repair the rupture. Follow-up treatment might include medication as well as physical and speech therapy.
For cluster headaches the goal is preventing future cycles with steroids, calcium channel blockers, antiepileptic drugs, or triptans. "Some are easy to treat with medications while others are resistant to them," says Dr. Marcus. "If the first treatment doesn't help, there are other options to try."
7. You develop a headache when you sneeze, cough, or go for a run -- or you often wake up in the morning with head pain.
Possible cause: These are potential signs of a brain tumor, but don't panic. Exertion is a common headache trigger and you may wake up with a headache if you didn't sleep well. Tumors, on the other hand, are rare -- they cause less than 1 percent of all headaches. "And by the time a brain tumor gives you a headache, you usually have other symptoms, such as blurry vision, weakness, or trouble thinking or talking," says Dr. Silberstein.
What to do first: See your doctor pronto. You may need a neurologist.
Getting treated: The first step is usually a neurological exam, plus imaging tests such as a CAT scan or MRI. If everything's clear, the usual headache remedies -- such as NSAIDs or acetaminophen -- should work. If they do find a tumor, you may need surgery. Afterward your doctor could recommend radiation, chemotherapy, and additional treatments.
Eat before parties: An empty stomach can make your head pound, especially if you're sipping a cocktail, says Dr. Diamond.
Switch to white wine: Red wine often triggers headaches, especially in people who get migraines.
Get rid of fumes: Heavy aromas, including those from perfumes, gasoline, and cigarette smoke, may be triggers, too, says Dr. Diamond.
Pop a caffeine pill: If you get a morning headache after sleeping late, it could signal caffeine withdrawal. Dr. Silberstein's paradoxical cure? "Get up a little earlier and take a NoDoz pill, which has caffeine, then sleep before the pill kicks in. You'll wake up without a headache."
Book a massage: "This is wonderful for tension headaches," says Lauren Richter, DO, of the University of Maryland Center for Integrative Medicine.
Take computer breaks: Stop every 20 minutes or so to look up and stretch your neck; you'll short-circuit the pain.
Block pain: Acupuncture is one of the best alternative remedies for migraines and tension headaches, according to a study done in 2009 by the Cochrane Collaboration.
Cut the glare: Avoid eyestrain by getting an antireflective coating on your eyeglasses and an antiglare screen for your monitor, says Ray Chu, OD, of the Southern California College of Optometry.
Pretreat it: Taking ibuprofen or naproxen can stop you from getting exercise headaches. Pop one before you begin your workout.
Cuddle up: If pain is coming on, head for the bedroom -- an amorous adventure is a surprisingly good headache cure. "It gets the endorphins going," says Dr. Silberstein.
Originally published in Ladies' Home Journal, October 2010.