Migraine, Cluster Headaches

Migraines – in a nutshell

Typical for migraines are seizures occurring pulsating headache, which usually affect only one side of the head and mainly the area around the forehead, eyes and temples and worsen when moving.To the pain must be added symptoms such as nausea, loss of appetite, sensitivity to light or noise. Part of the pain is preceded by a so-called aura, in which symptoms such as visual disturbances announce the subsequent headache. In order to quickly stop or avoid the attacks, it is important to take the individually appropriate medicine at the right dose at an early stage. Migraine sufferers should therefore seek the advice of a doctor. With frequent attacks also a preventive treatment is possible buy imitrex online.

What is migraine?

Migraine refers to certain seizure-related headaches (migraine attacks) that are aggravated by exercise. In addition to the   a headache   need other symptoms such as   Nausea ,   anorexia   or light and noise hypersensitivity occur. Sometimes the headache has special sensations like for example   blurred vision   ahead, the so-called migraine aura.

Migraine is a common disease: About seven percent of men and 13 percent of women have migraine attacks. The most common migraine attacks occur between the ages of 35 and 45 years. About three times more women than men are affected at this age. Every fifth woman has migraines during her life. Already school children can suffer from migraine, but is typical for a first appearance after puberty. Migraines are more familiar. Background is a genetic predisposition to migraine, which has now been proven for some forms.


Treat migraines properly

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There are many types of migraine known. Most common are headache attacks without a prior aura. This type of migraine occurs in about 80 percent of cases. In a migraine with aura headaches are preceded by certain symptoms. For example, visual disturbances,   Tingling sensations , speech disorders,   dizziness   or rarely even paralyzes occur. Certain types of migraine also have other symptoms.

Most migraines are episodic with individual headache attacks and the clear predominance of headache-free days. If the attacks become more frequent and, finally, days with headaches are more common than days without, doctors call this chronic migraine.


The exact cause of the migraine is unknown; However, we now know a lot about the biological processes during an attack. Also, many factors are known that can trigger a migraine attack (trigger).Such triggers vary from person to person.

They especially count among them   stress   and lack of sleep that can occur in an irregular lifestyle. Migraine attacks often start when drinking too little (volume shortage). Even omitting a meal or fasting can trigger attacks on some sufferers. Many women have migraine attacks shortly before and at the beginning of menstruation. Migraine can also be triggered by overstimulation. Other trigger factors are probably certain weather conditions (for example hair dryer). Similarly, medicines containing nitro compounds may cause certain alcoholic beverages, such as red wine, and caffeine withdrawal migraine.

Which processes in the brain cause the typical migraine headache is not explained in detail. There are many indications that some nerve networks are overly excited in the event of a migraine attack. Nerve ends of the trigeminal nerve, which supplies parts of the head and face, are activated, triggering a process called neuro-vascular inflammation. This causes an inflammatory reaction with irritation of the blood vessels in the brain. The blood vessels expand and become more permeable to certain molecules. An important messenger that plays a major role in this is called CGRP (calcitonin gene-related peptides). CGRP contributes to the transmission of pain signals.


Migraine attacks can be very different. A migraine attack is usually divided into certain phases. These take different lengths and do not necessarily have to occur.

Vorbotenphase (prodromal phase)

For example, a few hours to two days before the migraine headache may have one of the following symptoms:Irritability, mood swings

Tiredness, yawning

Cravings for certain foods

difficulty concentrating


increased sensitivity to light and noise

Migraine aura

Subsequently, perceptual disorders can follow (migraine aura). These usually affect seeing (visual aura). For example, migraine aura can cause flickering or seeing zigzag lines, visual field defects (scotoma) or those affected see objects partially distorted, out of focus, enlarged or reduced (metamorphopsia). The second most common aura symptom is sensory disturbances with a tingling sensation that slowly spreads from the hand over the arm to the head. Also the ability to speak may be disturbed (aphasia). Very rarely it comes to orientation disorders and paralysis (paresis). The migraine aura is sometimes associated with balance disorders. The symptoms of a migraine aura, unlike a stroke, are typically slow and fade away as slowly.

Headache phase

In almost every migraine attack occur   a headache   and partly too   nausea   With   Vomit   on. The person concerned is sensitive to light (photophobia), noise (phonophobia) and odors (osmophobia). The most severe headaches occur in most cases half-sided (hemicrania), but may also affect the entire head. From the point of view of pain, the pains are pulsating or pungent, especially in the area of ​​the forehead, temples and eyes. When moving, the symptoms increase; Rest and darkness ease them.

The headache phase of the migraine attack will last for at least four hours if left untreated and may last for up to three days.

Recovery and recovery phase

Even if the headache and other symptoms of   migraine   When patients have died down, many patients still complain of tiredness and fatigue for hours to a day or two.

Special features of children and adolescents

Children and adolescents typically have shorter migraine attacks. They usually perceive the headache on both sides of the forehead and temples. Also with them balance disorders are common.


To diagnose a migraine, the doctor first asks about the symptoms. Among other things, he will ask about the frequency and duration of the seizures, the type and strength of the headache and concomitant symptoms. A headache diary can help answer these questions. In this way, the doctor can usually already close on the diagnosis of migraine and differentiate it from other types of headaches and other diseases. However, a physical neurological examination is also part of the diagnosis. Typically, migraine does not show abnormalities here. If abnormalities are found that can not be explained otherwise, further additional examinations must be made. Even if the symptoms are not clear enough for migraine, further research may be needed to rule out other conditions that also cause headaches. These include, depending on the suspected diagnosis, the examination of the nerve water ( lumbar puncture ), a blood sample, a   Ultrasound examination (Doppler sonography), imaging techniques such as computed tomography (CCT) or magnetic resonance imaging ( MRI ) and an electroencephalogram (EEG).

Different migraine forms

There are several forms of migraine that the doctor can diagnose.

Migraine without aura

The most common migraine is without aura. There are headaches and other symptoms without an aura preceding them. In women, migraine without aura is often associated with the menstrual cycle and occurs most often before and during menstruation.  

Migraine with aura

In about every tenth case, a migraine is associated with an aura. It tends to be more common in men. In rare cases, a migraine-typical aura may occur without following a headache phase.

In addition to the common types of migraine other forms are known.

Familial hemiplegic migraine

Familial hemiplegic migraine, in addition to the migraine symptoms, causes hemipteral paralysis, which decreases after the attack. This type of migraine usually affects several members of a family and the susceptibility to this is inherited as an autosomal dominant.

Retinal migraine

In so-called retinal migraine, in addition to the headache on one eye, there is a slowly progressive loss of visual field, which completely recedes in the course of the disease. Rarely blinded sufferers for several minutes in one eye.

Migraine with so-called brain stem aura

Brainstem arachnida is very rare and occurs more frequently in young women. It is accompanied by pain in the back of the head, disturbance of consciousness (drowsiness to coma), vertigo, visual disturbances such as double vision and discomfort on the hands and face.


Also complications are possible. In the rare status migraenosus, the migraine persists for more than three days. The aura phase may take more than an hour. Furthermore, it can very rarely become one   stroke   during the migraine attack (migraine infarction). With these complications and if the migraine symptoms differ from usual, the patient should be examined by a doctor to make sure that it is a migraine attack and to avoid long-term consequences.

If the aura lasts longer than a week, there is a persistent aura. Migralepsia is a form of migraine in which the aura becomes an epileptic seizure. An ordinary migraine can develop into a chronic migraine. In this case, the symptoms persist for more than 15 days a month.


In the treatment of migraine, a distinction is made between therapy for the relief of an acute headache attack (acute therapy) and preventive therapy (prophylaxis), which aims to reduce the frequency of attacks, to relieve the severity of headaches and to respond to the acute therapy improve. For acute therapy are primarily analgesics suitable, which are often directed against inflammation. They can be combined with medication for nausea. In addition, there are also migraine-specific analgesics. For preventive treatment, there are also drugs that can also be combined with non-drug therapies to reduce migraine attacks.

For appropriate therapy, patients should seek individual advice from their physician.

Treatment of an acute migraine attack

In the acute migraine attack, a number of medications are helpful. For mild to moderate symptoms, the early intake of painkillers (non-opioid analgesics, non-steroidal anti-inflammatory drugs) in appropriate dosage helps. Your doctor or pharmacist can give you this information. Particularly suitable in adults are ibuprofen, naproxen, paracetamol, acetylsalicylic acid (ASA) or diclofenac.Chewable or effervescent tablets are absorbed most quickly by the body. Paracetamol works best as a suppository (rectally). If a migraine attack is accompanied by vomiting, medications may help against nausea (antiemetics). They stimulate the stomach movement, which is slowed down by the migraine. This also improves the absorption of the painkillers into the blood. Painkillers should not be used more often than ten days a month, otherwise permanent headache as a side effect is possible.

For more severe symptoms of migraine migraine-specific drugs, called triptans, are recommended. They block the neurovascular inflammation, constrict the dilated blood vessels and thus counteract the headache and the other accompanying symptoms of migraine, such as nausea and vomiting. Triptans also help best if taken early, but they can be used at any time of a migraine attack. If no effect occurs, it is not recommended to take another dose in the attack. Triptans must not be used in untreated hypertension, coronary heart disease, and other vascular diseases. Regular use of triptans for more than ten days a month can cause a chronic headache, which can only be interrupted by withdrawal from the triptans.

For the treatment of migraine, ergot alkaloids (so-called ergotamines) were formerly used. They are still available but because of their side effects means of second choice. Ergotamine should never be taken with triptans.

Medicamental migraine prophylaxis

For frequent and severe migraine attacks migraine prophylaxis is advisable. Your doctor will choose the right drug for you. Often used as a first-line drug are substances that were originally developed for other diseases, but have proven their migraine-preventive effects in targeted studies. These are beta-receptor blockers (eg metoprolol), anticonvulsants (eg topiramate) or antidepressants (eg amitriptyline). But there are also many other medications. In addition, from November 2018, newly developed drugs, known as antibodies, block the messenger substance CGRP in its action. CGRP plays a significant role in the development of migraine attacks.

The effect of drug-based migraine prophylaxis does not begin until six to eight weeks and is particularly effective when the drugs are also combined with other non-drug therapies for the prevention of migraine.   Relaxation methods (such as the Jacobson progressive muscle relaxation), endurance sports, biofeedback procedures,   acupuncture   and, if appropriate, a behavioral therapy , for example, with stress management training, reduce the susceptibility to migraine. Drug prophylaxis is required in many patients only temporarily for half a year or a full year. When the monthly number of migraine attacks has decreased, the non-drug measures are often sufficient for further prevention.

Migraines in children and in pregnancy

Already children can be affected by migraine. With them, medicines can be associated with special side effects. However, this is no reason to deny children a drug therapy. However, medication should only be given after consultation with the doctor. Many active substances are only approved for young people.

Even during pregnancy, migraines can be treated. In any case, a migraine treatment in pregnancy should be discussed with a qualified doctor to prevent damage to the unborn child by medication.Fortunately, many affected women temporarily lose their migraines during pregnancy.

Self-help measures in migraine

Measures such as a regulated lifestyle and endurance sports have a preventative effect. Relaxation exercises also help to become less prone to migraines. For example, progressive muscle relaxation according to Jacobson or autogenic training are suitable, as well as very individual strategies to relieve stress. Strong ambition and perfectionism lead to tension and stress – and can trigger the migraine with appropriate tendency.

When migraine attacks occur, it usually helps those affected to retire into a dark and quiet room. Sleep is often relieving. In addition to the acute treatment with medication, diluted peppermint oil can be applied to the temples or cooling wipes can be applied to relieve headaches. Those affected usually know best what helps them in the case of a migraine.

What types of headaches are there?

Almost everyone knows a headache. However, chronic headaches, which are very common over a long period of time, can severely affect a person’s health and life and even lead to disability. In the list of the world’s most debilitating diseases, the World Health Organization puts migraine in seventh place. Around 54 million people in Germany suffer from headaches during their lifetime. The two most common forms are tension-type headache and migraine, which together make up around 90 percent of all headache disorders. The tension headache is 63 to 86 percent more common than migraine, which affects up to 16 percent of the population. Sometimes the different forms also occur in combination: migraine sufferers sometimes suffer from simultaneous tension-type headaches.
In principle, over 200 known, different types of headache are classified by the International Headache Society (IHS) into two major groups:

1. Complaints that occur on their own, ie can not be attributed to a cause (= primary or idiopathic headache):   Over 90 percent of all headaches that lead patients to the doctor are among the primary headaches. Examples of primary headache disorders are migraine, tension or cluster headache. But there are also several other types of primary headache.

2. Pain that occurs as a result of other illnesses (= secondary or symptomatic headache):   In addition to other symptoms, various illnesses can also cause headaches, which may then be in the foreground or may be the only symptom. Examples are manifold and range from infections to injuries of the head, side effects of drugs or other substances as well as their withdrawal, vascular diseases of the head or neck, damage of   Facial nerves or cervical spine, brain tumors to diseases of the throat, eyes, ears, nose, sinuses and teeth.

Headaches are not always the same. On the contrary, especially with primary headaches, the doctor can often draw conclusions about the type of headache that is already based on certain characteristics and the accompanying symptoms.

If you have a headache, you should therefore pay attention to some points to get to the bottom of the symptoms:

How often do the headaches occur? Chronic pain typically occurs at least 15 days a month, while episodes are rarer.

How long does the pain usually last?

How does the pain feel? Is it piercing (as caused by a knife), pulsating-throbbing or rather dull-oppressive, as if a weight were on the head?

Where does it hurt? Are affected only certain sections of the head (for example, the temple or the occiput), the pain occurs only on one side – even in alternation – on (one-sided) or is the entire head involved (bilateral headache)?

What improves the symptoms and what causes a worsening (for example, increase in pain when coughing, sneezing, pressing)?  

Which signs of illness occur together with the pain? These may include, for example:   nausea   and vomiting,   Vision disorders , speech disorders or paralysis, photophobia, neck stiffness or fever.  

When to the doctor?

If a headache first appears, if a known headache intensifies, or if it changes its character noticeably, a doctor must absolutely rule out a dangerous cause. Also, a loss of effect of previously helping medications, the new onset of nausea or vomiting, a change of nature or a loss of consciousness require the quickest possible presentation to the doctor. With age, the risk of dangerous headache increases, while in recent years, migraine and tension-type headache dominate.

A sudden change in headache symptoms should always lead to the doctor.

Even with recurring headaches, a doctor should clarify the cause, before resorting to self-help or over-the-counter medicines from the pharmacy.

If children have a headache, you should definitely visit a pediatrician with them.   drugs   Children should only be given pain relief after consultation with a doctor or pharmacist to ensure that it is a preparation that is suitable for children and that the appropriate dosage is being used. Often ibuprofen or paracetamol are used. Children under the age of 14 should not be treated with acetylsalicylic acid (ASA). Here threatened with them, especially in connection with infections a dangerous injury of   liver   and brain, the so-called Reye syndrome, the cause of which has not yet been definitively clarified.  

Important note for pregnant and nursing women:   Many medicines are in the   pregnancy   and breastfeeding are not suitable or may even cause harm to the unborn child or infant. Therefore, pregnant women and nursing women should be advised by a doctor or pharmacist before taking any medication.

To find out what type of headache it is, the doctor gives a detailed medical history. Among other things, he asks about the frequency, nature and duration of the pain, the area of ​​the head in which they occur and other symptoms that occur together with or in front of the headache, such as blurred vision, tearing or red eyes, as well as Vomit. It is also interesting to see if there are any other people in the family who are suffering from headaches and what relieves or aggravates the pain.

Following the medical history, the doctor examines the patient. He assesses the functions of the nervous system exactly. This is important, because abnormalities in the examination are a possible warning sign for a symptomatic and thus potentially dangerous headache. On the other hand, the doctor can make the diagnosis in typical medical history and inconspicuous physical examination, without further investigation procedures are needed.

However, if a known headache increases, the symptoms change, or the doctor can not clearly identify the symptoms with a group of primary headaches (especially when they first occur), it is important to make sure that there is no other illness behind them. The same applies if in addition to the headache certain symptoms – such as blurred vision, speech problems, paralysis, seizures or  numbness   – occur.

In order to get to the root of the problem, in most cases the brain is first examined using an imaging technique. Typically, this is a magnetic resonance imaging ( MRI ) that is best suited to rule out a dangerous cause. Alternatively, in acute cases where there are headaches that have recently started, for example, to exclude a fresh brain hemorrhage, a computed tomography of the skull   (CT) make sense.

In addition to these imaging examinations, the physician has a wide range of diagnostic procedures to choose from, which can help him confirm his suspected diagnosis and / or rule out serious illnesses. When it comes to whether there is a seizure disorder ( epilepsy ), for example, a record of the brain waves (EEG) can be clarifying. On the other hand, if meningitis is suspected , it is necessary to obtain nerve fluid (CSF) for a laboratory test (see Meningitis). Sometimes it helps to determine certain blood levels – for example, the inflammatory parameters if the doctor believes that there is an inflammation of the temporal artery. Also, x-ray or ultrasound examinations may be useful, for example, if the suspicion of a   Sinusitis is or a tear in the brain supplying vessels in the neck area can be considered as the cause of the headache.

Primary headache

As mentioned above, there are primary headaches that occur on their own and secondary headaches, the cause of which is an underlying condition.

The most important primary forms of headache are migraine, tension-type headache, and trigemino-autonomic headaches, such as cluster headache. However, there are several other types of primary headache that may be situational, for example.

Tension-type headache  

Tension-type headache (the exact term for tension-type headache) is the most common type of headache.

Typically, tension headaches last between 30 minutes and a week. According to International Headache Society, neither vomiting nor nausea should occur, and at most one of the two symptoms  photophobia   and noise sensitivity. In addition, at least two of the following characteristics must apply:

•      Pressing or cramping pain that does not pulse 
•      Both headers are affected 
•      Mild to moderate pain intensity (everyday activities are still possible or only slightly limited) 
•      Physical activity does not increase the pain 

In addition, to diagnose tension headaches, at least ten such headache periods should have occurred during the course of life.

There are three different types of tension headaches:

1. rare and transient (episodic) pain: in less than one day per month (less than 12 days per year)

2. frequent and transient (episodic) pain: over at least 3 months but less than 15 days per month (at least 12 but less than 180 days per year) headache for at least three months

3. persistent (chronic) tension-type headache: at least 15 days per month for at least 3 months (more than 180 days per year).

While patients rarely go to the doctor because of episodic tension-type headache, chronic tension-type headache is a very debilitating condition. Because it is so unspecific, symptomatic headaches can be concealed, so that usually a diagnostic apparatus, such as an MRI of the skull is necessary.

The cause of the disease has not yet been finally clarified. Tense muscles are often seen in the skull and neck area. Scientists suspect that these frequent painful perceptions, especially in the chronic form, change the function and shape of brain regions involved in pain processing. So then drops the threshold from which a stimulus is perceived as pain.

In acute tension-type headaches, the analgesics acetylsalicylic acid (caution: not in children under 14 years), paracetamol, ibuprofen, naproxen or metamizole may help. Also, mixed preparations containing analgesics and caffeine to enhance the effect, can be used in acute tension headache. For some people it helps to apply peppermint oil on their temples and neck extensively. But be careful: do not put the oil on or in the eyes.

The more frequently the tension-type headache occurs, the more meaningful is usually a preventive treatment (prophylaxis) with medication. Also, people with frequent tension headaches should be advised by the doctor. As is the case with other primary headaches, excessive use of acute pain remedies can lead to headaches, which are caused by the too frequent intake of painkillers. Therefore, patients with frequent or chronic tension-type headache should take these medicines for a maximum of 10 days per month.

In chronic tension-type headaches, relaxation exercises (for example, progressive muscle relaxation according to Jacobson), endurance training (such as   Jogging , swimming or cycling) as well as other stress management measures to reduce the number of headache episodes. Drugs of choice for the prevention of frequent tension headaches are antidepressants like amitriptyline. These are not used, because it is suspected that those affected are actually depressed, but because they can affect chronic pain conditions favorable.

In adults, migraine is the most common type of headache that drives patients to the doctor. However, most of them fall ill for the first time in childhood and adolescence. Before puberty, the frequency is four to five percent. Boys and girls are affected just as often. Migraine attacks are most common between the ages of 35 and 45 years. At this age, women suffer three times more often than men. 

Typical for migraine are attack-like, strong and pulsating headaches, which usually concentrate on one half of the head and can be amplified during physical activity. The pain occurs seizure-persistently for four hours to three days. Accompanying, noise, light and odor sensitivity, nausea or vomiting usually occur. Only a third of patients complain of pain throughout the head. If the headaches are one-sided, they can switch sides within a seizure or attack to attack. Because the pain increases due to physical exertion, the tendency to retreat is typical for migraine sufferers: Sit down or lie down quietly and avoid head movements or exertion.

Many migraine sufferers report a onset of pain in the neck, which then radiates to the forehead in the further course. These are not the cause of the headache, but rather a consequence: in the context of the migraine attack pain is projected into the neck.

The diagnosis migraine relies on the typical symptoms and the course of the disease. According to the International Headache Society (IHS), the so-called main features for migraine are:

unilateral headache

pulsating pain

moderate to severe pain with a significant limitation of everyday activities

Aggravation of pain due to physical activity

As accompanying features the IHS designates:

Nausea and / or vomiting

Photosensitivity and noise sensitivity

For the diagnosis of migraine, there must be at least two main features and an accompanying feature. The duration of the untreated attacks must be between four and 72 hours and the doctor should be able to rule out that another disease is the cause of the headache. In addition, the current headache attack should have been preceded by at least five more in the course of life.

Even before the onset of the headache, they can announce to the person affected by certain symptoms such as blurred vision, flashes of light and feelings of numbness. This phenomenon usually lasts about five to 60 minutes and is called aura. An aura is common in about 20 percent of migraine sufferers, and more rarely an aura. A common form of aura is the flicker scotoma. As a rule, a flicker starts from one point and increases slowly. The fringes are jagged, in the middle it flickers mostly. One and the same person can suffer both from attacks with and without aura. Especially older people with a known migraine with aura experience with increasing age only an aura, without subsequently developing the full picture of migraine headache.If these auras recur without a known migraine, it may also be a different disease and further investigation is needed.

Even before the aura begins, there may be so-called harbingers, such as general malaise, cravings, or mood changes. Experienced migraine sufferers, and more often their relatives, can use these signs to predict that an attack is imminent. From recent studies it is known that at this time the migraine attack has already begun and thus the term harbinger is actually not completely correct. The delimitation of triggers can be problematic. These triggers are not the same for every migraine sufferer. Such triggers can be, for example, stress, lack of sleep or a changed daily rhythm. Therefore, it is worthwhile at the very beginning to keep a headache diary and to record potential trigger factors. The example of cravings, for example on chocolate becomes clearthat delineation between triggers and harbingers can be difficult, as the chocolate may trigger an attack, or the harbinger of cravings for chocolate may be the result of an approaching attack.

More information about migraine and its treatment can be found in the guide migraine . 

Trigeminoautonomic headache

Trigemino-autonomic headache is a group of attack-like, severe headaches. They only spread to one half of the head, mostly in the area of ​​the temple and around the eye. The pain is regularly accompanied by other complaints on the affected side: redness of the eye, tearing, runny nose, stuffy nose, the so-called Horner syndrome (= narrowing of the pupil, sunken eyelash, drooping upper eyelid) or swelling of the face. Unlike migraine, patients complain of physical restlessness that causes them to walk around, or to rock when sitting.

The different forms of trigeminoautonomer headache differ mainly by duration and frequency of the attacks. The shorter the attacks, the more common they usually appear. They can all be in an episodic form and a chronic form. In the chronic form, headaches occur practically daily for over a year. A complaint-free period exists for a maximum of one month. If, on the other hand, the episodic form is present, those affected can in the meantime also be completely free from symptoms for a period of several weeks to years.

If there is a suspicion of trigeminoautonomic headache, it is imperative to have diagnostic imaging and a neurologist’s assessment to rule out other forms of headache. There are also diseases such as trigeminal neuralgia that need to be differentiated. The difference lies in the Trigeminusneuralgie with their extremely short (usually less than a second) ongoing attacks also in the fact that the typical accompanying symptoms such as watery eyes or runny nose missing.

Cluster Headache:

Cluster headaches typically occur more often over weeks (hence the term “cluster” = heap) up to eight times a day, characteristically also at night. The individual headache attacks last between 15 and 180 minutes and often occur at similar times during the day, often one to two hours after falling asleep or in the early morning hours. Those affected feel violent, one-sided headache, usually in the area of ​​the forehead or the eye. They cause them to move and, for example, to walk around or sway with their upper bodies. This “motor unrest” is typical of the disease and reliably differentiates cluster headache from migraine. Also typical are accompanying symptoms such as a watery or reddened eye,a runny and / or stuffy nose or Horner syndrome (drooping upper eyelid, narrowed pupil and sunken eye). These symptoms always occur on the same side of the head as the pain. Men suffer from cluster headache three to six times more frequently than women.

In the vast majority of cases of cluster headache, there is the episodic form, in which phases of daily attacks occur over a few weeks to months. In between there are trouble-free periods that can last for months to years. If the cluster period lasts one year and more without interim painless phases, or if the symptom-free phases last less than two weeks, this is called chronic cluster headache.

Since symptomatic forms such as inflammation of the paranasal sinuses or tears of the carotid artery also exist in cluster headache, an imaging examination of the head, including a magnetic resonance examination of the head and the head and neck transition, should be performed, especially on initial appearance. In addition, further investigations may be necessary (for example, extraction and examination of nerve water).

Various therapeutic approaches can help with cluster headache attacks. Thus, in more than half of those affected the inhalation of 100 percent oxygen over a face mask effect. Some of the migraine-approved triptans may also help with cluster headaches, but only as a nasal spray (zolmitriptan) or as a syringe into the subcutaneous fatty tissue (sumatriptan). Another possibility is the administration of a local anesthetic (lidocaine) into the nostril of the site affected by the attack. Since not every method strikes every patient, sufferers should seek extensive advice from their doctor and, after consultation with him, may also try different therapeutic approaches.

Various drugs are suitable for preventing cluster headache attacks. Preferably, the calcium antagonist verapamil is used. But there are also various other medications, such as cortisone, lithium or certain antiepileptic drugs (eg topiramate), which are also used for the prophylaxis of cluster headache use. Your doctor knows the benefits and risks of the individual drugs and weighs them before he prescribes a suitable drug. Because of the side effects of the individual active ingredients, regular medical checks and, depending on the drug, further examinations, such as the determination of specific blood values ​​or regular measurements of the cardiac currents ( ECG ), are necessary , especially at the beginning of the prophylactic therapy .

Paroxysmal hemicrania:

Paroxysmal hemicrania are also usually unilateral headache attacks, which differ from cluster headache with shorter (about five to thirty minutes) but more frequent seizures. This headache affects women more often.

If the headache first appears, it should be the occasion for further diagnostics by the doctor.

The special feature of paroxysmal hemicrania is that it is always and completely eliminated by the active ingredient indomethacin. If the doctor administers the medication and the symptoms disappear within days, this is an unerring sign that a paroxysmal hemicrania is present. In addition to the attack-like hemicrania, there is also a persistent form of this headache, called hemicrania continua, which also improves immediately on indomethacin.

About dosage, type and duration of therapy, patients should consult with their doctor. In pregnancy and lactation indomethacin is not suitable. Since indomethacin, like many analgesics, reduces the protection of the gastric mucosa against acid, patients with gastric problems should, if appropriate, additionally receive gastric protection in the form of an acid blocker.

Note: Currently (September 2018) there are some difficulties with the supply of indomethacin.


The SUNCT syndrome is characterized by very short (seconds to minutes) persistent unilateral headache attacks with concomitant reddening of the conjunctiva of the eye and lacrimation.

For the first time, when the headache occurs, the physician will report conspicuous findings or be ambiguous, for safety’s sake to exclude other causes, a CT scan of the skull base and a magnetic resonance scan of the head and head and neck, and if necessary still further investigations are made.

Currently, a generally effective therapy is not known. The drug of first choice, but not all satisfactorily helps, is lamotrigine. Doctors will tailor the treatment to the individual situation of the patient and will discuss the benefits and risks of the therapy with him.

Other primary headaches

There are many other types of primary headache that can not be classified in the three groups described so far. Most of these headaches are harmless and there are no significant causes behind it. Nevertheless, one should also clarify this pain on first appearance by a doctor to rule out that there is a serious illness. In particular, in thunderbolt headache and headache in sexual activity, a cerebral hemorrhage should be excluded.

Some examples of other primary headaches:

Primary stabbing headache: lightning-like pains in changing parts of the skull without any accompanying symptoms

Primary cough headache: Minutes prolonged headache when coughing 

Primary exertional headache: headache lasting for hours during exercise or exercise

Headache with sexual activity: above all, before or during the orgasm occurring bilateral pain at the back of the head for minutes to hours

Primary thunderclap headache: Headaches that reach maximum intensity within one minute and then last for hours to days. Despite intensive diagnostics, no cause can be found

primary sleep-bound headache: so-called “hypnic headache”: headache attacks of a few hours duration, which occur especially in the elderly only at night (often always at the same time)

Secondary, symptomatic headache

Here are a few key causes of secondary headache. However, the list is by no means exhaustive, as there are so many reasons for secondary headaches (for example, a sunstroke, dentition, …) that a full enumeration would not be possible here.

Most people become acquainted with headaches in the course of their life, often in childhood, as part of an infectious disease, such as a viral infection. At the same time, various other symptoms (such as rash , cough, runny nose and fever) are more or less typical of the underlying condition. 

If the infection clears, the headache also disappears. A special treatment is therefore usually not necessary. Rest can alleviate the symptoms in some cases. If necessary, painkillers can also be used. However, children under the age of 14 should not use acetylsalicylic acid as it may cause dangerous liver and brain damage under certain conditions (Reye syndrome). Many medications are not suitable for pregnant or nursing women. You should always consult a doctor or pharmacist before taking any medicine.

Headache as a Result of Traumatic Brain Trauma Head trauma 
or injury, such as a traffic accident, a fall or a blow to the skull, can cause headaches.

After a craniocerebral trauma, a doctor should absolutely rule out that there was no bleeding in the area of ​​the meninges or the brain. Such bleeding can be life threatening. Warning signs are that the person was or is unconscious, is very sleepy or even apathetic, no longer adequately responds or his pupils are of different sizes. In these cases, it is necessary to immediately alert a doctor or visit a hospital.

If clear fluid or blood flows from the ear or nose, this could be an indication of a fracture of the skull base. In this case, a hospital must be visited immediately or the emergency physician called.   


Headache as a Result of Cerebral Hemorrhage or Subarachnoid Hemorrhage (SAB) 
Headaches can also occur as a result of bleeding around the brain or meninges. Sudden, extremely severe headaches, often followed by delayed neck pain , may, for example, indicate a so-called subarachnoid haemorrhage. In about 50 percent of cases, this pain is accompanied by nausea, vomiting, and impaired consciousness. Some people also develop paralysis and epileptic seizures. Typically, patients complain of photophobia and neck stiffness.   

If you suspect a subarachnoid hemorrhage, call emergency services immediately!


There are several types of cerebral hemorrhages. Depending on size and location, the symptoms are different. Find out more here

Headache as a side effect of drugs or other substances and their withdrawal 
Headache can also occur as a side effect of various medications. The contraceptive pill or other hormonal contraceptives, nitrates and phosphodiesterase inhibitors are just a few examples of some of the typical remedy groups that can cause headaches.

Unfortunately, overuse of analgesics can also cause headaches. It is defined as “too frequent” if a patient takes painkillers or migraine medication (triptans, ergotamines) for more than three months for more than 10 days per month. These should not be taken for more than three days in a row. The amount of painkillers in a day plays a less important role.

But not only medicines, but other substances can cause sensitive people’s head hurts. Thus, alcohol, drugs, and certain food ingredients or supplements (eg, nitrates, histamine) may also be responsible for the pain.

Also, the withdrawal of regularly consumed substances can cause headaches. The best known example of this is caffeine withdrawal, which causes headaches in people who normally consume large amounts of this substance. In particular, migraine sufferers report again and again that caffeine withdrawal leads to attacks in them.

Headache as a result of irritation of the meninges / meningitis 
Irritation of the meninges (meninges) may also result in headache. Meningitis is an inflammation of the brain and spinal cord, which is usually caused by infections , for example, with bacteria (purulent) or viruses (non-purulent). 

The bacterial meningitis is characterized by three typical symptoms: headache, neck stiffness and fever. Signs of bacterial infection of the skin or lungs and typical skin lesions with bleeding into the skin may support suspicion. In addition, concomitant symptoms such as photophobia, nausea and vomiting as well as drowsiness and epileptic seizures may occur.   

If you suspect a meningitis, please contact the doctor immediately!


Inflammation of the temporal artery (giant cell arteritis, temporal arteritis) 
The giant cell arteritis is a disease that primarily affects people over the age of 50. It is a vascular inflammation that belongs to the diseases of the rheumatic type. It occurs suddenly (acute) or less violent and delayed (subacute). In addition to one-sided or bilateral piercing-boring headaches, there is often a painful hardening and / or weakening of the small artery on the side of the temple (temporal artery). In addition, other symptoms such as an increase in body temperature, pain when chewing, loss of appetite and possibly also weight loss occur. Also typical are visual disturbances     that can lead to complete blindness. If diagnosis and therapy are not initiated in time, the complete loss of vision or the occurrence of strokes is threatened. Giant cell arteritis occurs in more than half of cases with a form of muscular rheumatism (polymyalgia rheumatica), which causes pain in the shoulder and pelvic girdle muscles and joints. As therapy cortisone preparations are used.


Giant cell arteritis (previously: temporal arteritis)

Temporal headaches and visual disturbances, which first appear at over 50 years of age, may be symptoms of giant cell arteritis. It needs to be treated quickly

Sinus vein thrombosis Clogging of the large veins 
in the brain, for example, by a blood clot is called a thrombosis of the sinus veins. It leads to the obstruction of blood flow out of the brain and to increase the pressure in the brain. Most of the headaches are oppressive and strengthen when lying down. Sinus vein thrombosis can quickly lead to cranial nerve failure, hemiplegia and epileptic seizures. It is therefore important to see a doctor quickly. In addition to coagulation tests, the diagnosis is made by means of magnetic resonance tomography (MRI), which should be coupled with a representation of the cerebral vessels (MR angiography) or a computed tomography. 
The therapy for sinus vein thrombosis depends on the underlying cause. By anticoagulant measures, the blood flow is to be improved and prevents the thrombus increases. Does an infection, for example, a delayed middle ear inflammation in the emergence of the thrombus a role are antibiotics and possibly even surgery necessary.

Dissections of the Cerebral Arteries 
In a dissection, the inner vessel wall ruptures one of the brain-supplying arteries . Dissections can be caused, for example, by injuries (such as a fall with a collision on the neck) or due to connective tissue diseases, but also without demonstrable cause. Dissections of the large cerebral arteries lead to sudden hemipteral headache or neck pain. Due to the tearing in the vessel wall, on the one hand, a clot can form, which then dissolves, on the other hand, the affected vessel can completely close. Both can then lead to a stroke .   
Between the occurrence of the vascular dissection and the circulatory disturbance in the brain can be a period of several days, in which the vascular damage is detectable only by magnetic resonance imaging. Sometimes, however, a unilateral Horner syndrome (= pupil narrowing, sunken eyeball, drooping eyelid) on a dissection of the large internal carotid artery (internal carotid artery) out. Similarly, when bleeding occurs, signs of cranial nerve damage – such as dysphagia, tongue paralysis, and speech disorders (dysarthria) – may encourage the suspicion of dissection of the carotid arteries. 
If you suspect a dissection of the cerebral arteries immediately to the doctor! A   Ultrasound examination of the cervical vessels may give evidence of a dissection. However, a reliable diagnosis is first provided by computer or magnetic resonance tomography with simultaneous angiography of the vessel. 

Diseases of the Neck, Teeth, Eyes, Nose, Paranasal Sinuses … 
Various other diseases can also cause headaches. In particular, here are diseases of the cervical, head or facial area to name but also some systemic diseases such as severe hypertension or sunstroke can cause headaches. In rare cases, myopia, whose defective vision has not yet been corrected, may suffer from pain in the head. However, this is generally overestimated. An inflammation of the sinuses or a malocclusion may also cause this symptom.   

Brain Tumors 
Contrary to the most common concerns of headache patients, brain tumors are a rare cause. However, a tumor as a cause should be considered especially if, in addition to the headache, epileptic seizures occur, a change of character is observed or if morning vomiting occurs at the same time. If there are such symptoms, or are there other reasons that make the presence of a brain tumor likely, such as a history of cancer, it is important to clarify brain imaging.


Brain tumors

There are many benign and malignant tumors in the brain. What symptoms they produce, how a brain tumor can be treated

Increasing the pressure of the nerve water (pseudotumor cerebri) 
Increasing the pressure in the nerve water (cerebrospinal fluid) can also lead to headaches. Because headaches occur without any tumor or other cause being detectable, it is called a pseudotumor of the brain. The CSF findings, ie the composition of the nerve water, is also inconspicuous.

The main symptom of pseudotumor cerebri is a headache, which often has oppressive character. Visual disturbances (visual irritation, visual field loss, impaired vision, double vision) and ear ringing ( tinnitus ) accompany the headache. The pseudotumor cerebri is mainly found in overweight women of childbearing age, but can rarely affect men.

Examination of the ocular fundus provides characteristic findings suggesting that the optic nerve is compromised by cerebrospinal fluid pressure. The decisive diagnostic measure, however, is the measurement of CSF pressure. A mass in the head and sinus vein thrombosis must be excluded. 
The therapy is usually to drain nerve water and take special medication that reduce the formation of new nerve water, so as to reduce the pressure inside the skull. It is important in overweight always a normalization of body weight.

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