May 18, 2021 When is a Headache More Than a Headache?

Hai Sun, MD, PhD Watch for any of these seven red flags, which may indicate bigger problems.

Almost everyone feels the throb or tightness of a headache from time to time. “Headaches are common,” says Hai Sun, MD, PhD, Associate Professor of Neurosurgery and Assistant Director of Research at Rutgers Robert Wood Johnson Medical School as well as a RWJBarnabas Health affiliated neurosurgeon.* “But they can be complicated and in many instances are a harbinger of something more serious that needs medical attention.”

As painful—even debilitating—as they can be, some of the most common headaches aren’t considered threatening. These include tension headaches caused by temporary challenges such as stress, hunger, fatigue or caffeine withdrawal; migraines attributed to chemical or

structural abnormalities in the brain, which are often triggered by changes in a person’s environment; and cluster headaches, a series of short, painful headaches that are centered around one eye and that occur in cycles or patterns.

How can you tell a routine headache from a headache that signifies a bigger problem? “Usually, people have a history of these common headaches and know them well,” Dr. Sun says. “What’s more concerning are headaches that aren’t like any headache you’ve had before.”

Certain red flags, like the ones listed below, may indicate that your headache means something else.


1. Severe pain strikes suddenly.

If a horrendously bad headache—one that feels like the worst of your life—hits like a thunderclap, consider it an emergency. “Usually this signifies some type of brain bleed caused by an abnormality in the blood vessel system,” Dr. Sun says. “Go to the nearest Emergency Department to be evaluated.”

One possible cause is an aneurysm, in which a bulge that formed in a blood vessel has ruptured. Related possibilities include an arteriovenous malformation (AVM) caused when tangled veins in the brain disrupt blood flow, or an arteriovenous fistula created by abnormal connections between arteries and veins.

2. You also have a fever.

Headache accompanied by elevated body temperature could indicate an infection, such as meningitis. “Both viral and bacterial meningitis can be spontaneous, meaning they can occur without directly exposing the brain to viruses or bacteria, which is a potential risk of brain surgery,” Dr. Sun says.

Medications or conditions that suppress the immune system (especially infectious diseases like HIV) can increase your risks for meningitis, as can diabetes. Other symptoms of a brain infection can include stiff neck, sensitivity to light and nausea or vomiting.

3. Pain is worse in the morning.

Waking boosts blood flow to the brain and helps clear carbon dioxide that builds slightly as you sleep. Normally, you don’t notice the minor increase in brain volume that results. But morning headaches may occur if a mass or tumor gives the brain less room to expand and ratchets up pressure inside your skull.

“This can be what’s happening in people who did not have headaches before but then start to experience them daily,” Dr. Sun says. “Often, such pressure headaches get worse with coughing or sneezing.”

4. Other body systems aren’t working quite right.

A tumor insidethe closed box of your skull can directlycompress areas of the brain that govern

systems throughout the body. “If the mass is next to the speech area of the brain, you could have trouble speaking,” Dr. Sun explains. “Symptoms may be as subtle as occasional difficulty

finding words.” A tumor next to a brain region governing motor control could

cause mild weakness or clumsiness. A mass near nerves or muscles that involve eye function can lead to vision difficulties, such as blurriness. “These are all reasons to seek medical attention,” Dr. Sun says.

5. You’re very overweight.

Headaches in obese individuals are sometimes due to a condition called pseudotumor cerebri, or false brain tumor, in which pressure builds inside the brain as with a brain tumor, but no tumor exists. This condition affects women more often than men, and the cause of it isn’t well understood. However, these headaches can be accompanied by other tumor-like symptoms such as vision problems and dizziness.

6. You’ve hit your head.

“It’s well known that minor traumatic brain injury can lead to headaches,” Dr. Sun says. In fact, headache may be a key sign of concussion, as evidence of a concussion from a fall, sports injury or car accident generally doesn’t show up on a CT (computed tomography) scan.

As you get older, even a small blow can cause gradually worsening headaches due to tears in veins that lead blood to accumulate and create pressure in spaces that have been left by age-related brain shrinkage. “People often think nothing of it when the injury occurs,” Dr. Sun says. “But when we discuss their history, they’ll say, ‘Oh yeah, two months ago I bumped my head on the cabinet’ or ‘I had a minor car accident.’”

7. Headaches won’t go away.

Persistent headaches that you can’t relieve with conventional remedies should be evaluated. “If steps like rest, hydration and taking over-the-counter pain medications such as acetaminophen or ibuprofen don’t help after a week, or your headaches keep getting worse, don’t hesitate to discuss it with your doctor,” Dr. Sun says. “Even though they’re common, headaches

are worth investigating if they’re concerning to you.”

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*Dr. Sun is affiliated with Jersey City Medical Center, Robert Wood Johnson University Hospital New Brunswick, and Saint Barnabas Medical Center.