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3. Headaches that are not migraine

Headaches are not always easy to label. The same person may experience more than one type of headache. One type of headache may develop and evolve over time to a different sort of headache. So it can be quite challenging for any doctor – expert or not – to decide exactly what your headache is at the initial consultation or assessment.

Different headaches are identified and separated by the nature, description, site and severity of the pain as well as the wide range of symptoms associated with the pain. In crude terms, it is about pattern recognition – but there are exceptions to every rule and not all the patterns fit neatly in to the available ‘diagnostic boxes’.

We go to speak about tension-type headache, chronic daily headache, medication overuse headache and cluster headache. Some of the more idiosyncratic and less common headaches we speak later.

Before going to see your family doctor or headache specialist about your headache symptoms, spend some time writing down exactly where you get your headache, what it feels like and what symptoms you get with it. Think about what might bring on your headache or ease the symptoms you experience. If you have thought about these things in advance, it should make it easier to answer the questions you will be asked. This is and aspects of your headaches to consider we will list later. We go write information on recognising ‘red flag’ symptoms.

 3.1 Tension-Type Headache

Question: I have looked on the internet and I think I have a tension headache. How can I be sure?

Answer: Tension-type headache (TTH) tends to be described as tightness, or a band-like pressure. It is not usually associated with any of the migraine symptoms, such as nausea, vomiting or sensitivity to light or sound. Moreover, you can usually carry on with your daily activities and will usually respond to a single dose of a simple painkiller, provided it is used only occasionally. Tension-type headache tends to last for several hours over several days, for days or weeks, and may even come on at the same sort of time in the day.

Question: My headache is just like a tight band round my head. What sort of headache could it be?

Answer: A band-like headache is usually thought to be a tension-type headache (TTH). This can only really be confirmed by checking what, if any, other symptoms you experience with your headache. Tension-type headache tends to be diagnosed by what is missing as much as by what is present in terms of symptoms. If you do not have any symptoms of nausea or sensitivity to light, it is more likely that you have TTH rather than migraine.

Question: My headache gets worse through the day, but I never have to go to bed with them like my sister does. What sort of headache do I have?

Answer: Attaching a label with only this much information is not really possible. In general terms, though, if you can carry on doing what you want or need to do, it is more likely that it is a low-impact headache such as a tension-type headache. The fact that it gets worse through the day also suggests that this may be a tension-type headache.

If you answer ‘No’ to the following questions, it is more likely to be tension-type headache:

• Do you ever feel sick with this headache?

• Do you ever need to keep still with your headache or lie down?

• Do you ever feel as though you need to wear tinted glasses with your headache or avoid bright lights?

• Is the pain only ever on one side?

• Is it a throbbing, pounding headache?

If you can say ‘Yes’ to one or more of the questions, you have some migraines features to your headache. The more you can say ‘Yes’, the more likely that the headache is migraine.

Question: Sometimes I feel a bit sick with my headache but don’t usually have to go to bed. About once a month, though, I feel really sick with the headache and have to go to bed with it. Do I have one headache or two different headaches?

Answer: You may well have two different types of headache, and I sometimes refer to this as a mixed-picture headache. The high-impact headache that you get once a month is probably migraine. If your high-impact headache is migraine, it is possible that you will feel nauseated or a bit light-sensitive with a low-impact headache. Your other headache, which is a low-impact headache, and doesn’t send you to bed, is probably a tension-type headache.

Questions: On some days I get my normal headache and other times I get a headache that is so bad I have to go to bed. Are these different headaches?

Answer: They may be two completely different but separate headaches or be slightly different headaches that may be linked. If you read on, you may be able to work out what sort of headache you have.

If you get an occasional headache that lasts a few hours every now and again and is of low impact, this is probably a tension-type headache. If you get a headache that lasts a few hours most days, we need to think about it a bit more. It could be a chronic tension-type headache, a chronic daily headache or even a medication overuse headache.

A ‘go to bed’ headache that happens every now and again is usually migraine. A ‘go to bed’ headache that happens regularly with a less severe headache in between needs a little more thought and assessment.

If you are taking some sort of painkiller most days, it is possible that you have medication overuse headache. This can happen if too many painkillers are taken to treat headache symptoms. How to deal with these different types of headache we speak later.

Question: What I want to know is why, on a bright day, I can wear tinted glasses but on a really sunny day I have to wear very dark glasses or I get a migraine?

Answer: If you get regular or frequent migraine, it is not unusual to be a little light-sensitive in between attacks. Some people are more sensitive than others, some people are light-sensitive all of the time and some just in the few hours or days leading up to their next attack. It is this light sensitivity that may cause the headache to get worse or drop your migraine threshold to the point that a migraine is triggered. You need to use the tinted glasses between attacks as a result of this light sensitivity that gets magnified during the attack, so you then move on to dark glasses.

3.2 Chronic Daily Headache and Medication Overuse Headache

Question: My son’s GP says that he has chronic daily headache. What is that?

Answer: Chronic daily headache’ (CDH) is a label applied to a collection of different types of headache rather than a diagnosis in the way that migraine or cluster headache are. It describes a headache that occurs on more days than it is absent. CDH usually happens on more than 15 days in each month, and is present for some part of most days. It is a descriptive phrase rather than a formal diagnosis.

Question: I was involved in a car accident two years ago. I got a headache at the time but it seemed to settle after a few days. Then a week or two later it started again and I haven’t had a headache-free day since. What is causing my headaches?

 Answer: Making a diagnosis for someone with a daily headache is difficult without a lot more information:

• Did you get a bang to the head during the accident?

• Were you unconscious at any time?

• Did you suffer a neck injury or significant whiplash?

• Do you take any painkillers for your headache?

• If you do take painkillers, how often do you take them?

Any bang to the head can lead to a headache that is defined as a post-traumatic headache. It is not serious or ‘sinister’ and usually settles six to eight weeks after the injury but can persist for as long as two years. A headache that develops rapidly in the first few hours or days after a head injury is much more likely to give cause for concern than one that has persisted for months or years. The other issue is about your use of medication, which may have switched an episodic (occasional) post-traumatic headache to a medication overuse headache (MOH). If this seems to be the case, you should talk to your family doctor about ways to solve the problem.

Question: A colleague suffers a lot – virtually every day – with what seems to be a migraine. Is it possible to get a migraine every day?

Answer: No, migraine is by definition an episodic headache – it happens from time to time. Migraine cannot and does not occur every day for days and days or weeks and weeks. Your colleague may have migraine as part of a mixed picture headache, with some headache-free days, or she may have chronic daily headache (CDH) or medication overuse headache (MOH) with ‘breakthrough’ migrainous symptoms

Question: What is the difference between a chronic daily headache and a medication overuse headache?

Answer: Chronic daily headache (CDH) is a collective term loosely applied to a variety of headache types – and medication overuse headache (MOH) is one of them. The diagnosis of MOH can be confirmed only when all the acute headache treatments (painkillers and/or triptans) are stopped completely for at least six to eight weeks and the headache improves to a significant degree.

 Question: I use ibuprofen to get rid of my headache. I only take a couple every day, but I was looking on the internet last week and it said taking painkillers every day might make my headache worse. Can that really be right?

Answer: Yes, that is right. It is not advisable to take painkillers every day to treat headache symptoms. Any painkiller taken on a daily or near-daily basis may, in a susceptible individual, lead to daily headache rather than stop your headaches. This is more likely to happen if you take one or two tablets every day than four doses in one day once in the week.

Over-the-counter preparations containing codeine

 

Name of preparation                                                                      Codeine content

Boots Tension Headache Relief                                                                  10 mg

Nurofen Plus                                                                                           12.8 mg

Panadol Ultra                                                                                          12.8 mg

Paracodol 8 mg

Phensic Dual Action                                                                                 8 mg

Propain                                                                                                10 mg

Solpadeine Plus                                                                                       8 mg

Solpaflex                                                                                            12.8 mg

Syndol                                                                                               10 mg

Veganin                                                                                              6.8 mg

Question: My doctor said that, provided I avoid painkillers with codeine in them, I can’t get a drug-related headache. Is that right?

Answer: Yes and no. Painkillers containing codeine will lead more easily to a medication overuse headache but any painkiller taken regularly over time has the potential to do this. There is codeine in many preparations that you can buy over the counter (without a prescription), so remember to read the labels, just to be sure. The table above lists some of the common over-the-counter preparations that contain codeine.

Question: I get a headache every day and am finding it difficult to put up with. Why does this happen?

Answer: A daily headache can be caused by many things. It might be what is called a   ‘primary headache’ such as tension-type headache, chronic daily headache or cluster headache. It might be a ‘secondary headache’ resulting from another disease process, such as diabetes or an overactive thyroid, for example. You need to visit your doctor to see if they can identify your headache. The GP or a specialist will ask you a series of questions to assess your symptoms and decide what, if any, investigations are needed. Deciding what sort of headache you have is about weighing up the range of symptoms in combination with the results of any examination or investigations. A diagnosis is sometimes made on the basis of your history alone and confirmed by the results of normal tests. Once the doctor knows what type of headache you have, the right steps can be taken to treat it.

Question: I am getting a migraine every day but nothing I take for it seems to work any more. Why is this?

Answer: First of all, migraine cannot and does not occur every day, for days and days and days. Migraine is an episodic headache that occurs every now and again. Some of your daily headaches might be migraine but not all of them. If you use painkillers to treat all your headaches and take those painkillers on most days, it is possible that your headache is a medication overuse headache (MOH). MOH develops as your treatment becomes less and less effective against your headache and you try stronger and stronger painkillers to no avail. Your headache happens more and more often, so you take more and more painkillers. You need to talk to your doctor about the problem so that, between you, you can find a way to solve the problem. For advice on how to change your MOH back to an episodic headache. I get this pressure headache every day. It doesn’t last all day but it has been there for some of the day for the last three months.

 Question: Why will it just not go away?

Answer: Pressure headache in the absence of more typical migraine symptoms is probably a tension-type headache (TTH). Having a daily headache suggests a chronic TTH – provided you are not overusing painkillers. If you are overusing painkillers, you have a medication overuse headache and your headache will not improve until you stop taking them. If you aren’t using painkillers regularly, you may need to think about diet and lifestyle changes to raise your headache threshold or consider a preventative drug to try to settle the headache symptoms. Talk to your family doctor about the options that are available.

Question: My specialist told me I have a medication overuse headache. He said that it has happened because I take too many painkillers. I don’t take more than the recommended dose, so how can that be?

Answer: There are lots of theories about how this might happen. In general terms, the pain receptors within the brain change in some way and, as a result of that change, they become oversensitive, and instead of being ‘switched off ’ by the painkiller are in some way kept ‘switched on’. Any painkiller can cause this shift in receptor response. What seems to be important is how often you are taking the painkillers to treat headache symptoms. Research evidence suggests that it is how many days in the week that you take the tablets, rather than how many tablets you take in the day that leads to the shift in pain receptor response. The more regularly you take them, the more likely they are to lead to a medication overuse headache.

 Question: My doctor told me I have a medication overuse headache. I don’t think I use too much medication, so how did it happen?

Answer: Medication overuse headache (MOH) tends to creep up on you. You start off getting headaches every now and again. Some of them are worse than others. You try different tablets but nothing seems to work. You get something a bit stronger from the pharmacy; or you might go to your family doctor who suggests a stronger painkiller and says, ‘It’s fine provided you don’t exceed the maximum dose’ – and sometimes the headache goes away and sometimes it doesn’t. Before you know it, you seem to have a dull nagging headache every day. It’s not really very bad but you get used to it being there. You almost learn to live with it but then you start to get some really bad headaches for a day or perhaps two. You think about going back to the doctor but they settle down, life is too busy and you just reach for the pills. Anyone who takes regular painkillers to treat headache symptoms runs the risk of eventually feeding the headache rather than relieving it. Not everybody is affected in this way, and it is impossible to predict who might be affected. It can happen all too easily in some of the people some of the time.

Your family doctor or practice nurse should be able to offer you some help or support while you try to make changes.

Question: My family doctor has told me that I should stop taking so many painkillers. I just can’t imagine surviving without them. What should I do?

Answer: It is not uncommon to feel ‘I just can’t do without my tablets’ or ‘I don’t take too many because I never take more than it says on the pack’. But if you are taking tablets on a daily or near-daily basis, you may be feeding the headache rather than relieving it. The only way to find out if this is the case is to stop all the painkillers for at least six to eight weeks, often longer. If medication overuse is the cause of your headache, you should eventually experience a significant improvement in your headache symptoms or they may even settle completely. To begin with, though, you will probably need to talk to your family doctor about ways to cope without painkillers.

Question: My family doctor says I must not take too many painkillers, but if my headache is happening every day how can I get rid of it without taking them?

Answer: How often were you getting your headache three months ago, or six months ago, or perhaps a year ago? If your answer is ‘A lot less often than now’, you need to think about how your use of painkillers has changed. If they have slowly but definitely increased, it is quite likely that the painkillers are causing the problem now rather than solving it. The only way to get rid of the headache in the short to medium term is to stop all the painkillers. You cannot take any painkillers no matter how bad the headache gets during this ‘washout’ phase of treatment. Talk to your family doctor about what other drugs, that are not painkillers, you could use to treat the pain.

Question: Syndol was the only drug that helped my headache but over the last few months it hasn’t seemed to work so well, and I have to take them more often. What should I do?

Answer: Drugs such as Syndol have several different active ingredients (Syndol has paracetamol, caffeine, codeine and doxylamine). When taken occasionally to treat headache, it can work quite well. If it stops working so well and you start taking it more regularly, over time it may lead to an increase in headaches. As to what to do, you need to stop the painkillers for at least six to eight weeks. The headache may get worse before it gets better, but stopping the tablets is the only way to get back in control. Ask your family doctor what alternatives you can take in the meantime.  

Question: I seem to have a constant headache, and take several over the-counter painkillers a day. How can I make the headaches stop?

 Answer: If you are taking painkillers every day or even most days, it is possible that the painkillers are contributing to the headache. How often did you get your headaches when they first started? Did you take lots of different painkillers that seemed to work for a while and then they stopped working? The only way to stop the headaches if they are caused by the painkillers is to stop the painkillers for a minimum of six to eight weeks. This means taking no headache medication, no matter how bad the headache gets during this ‘washout’ phase. It may be that you need to see your family doctor for alternative pain treatment such as tricyclic antidepressants or anti-epileptic drugs. Both of these drugs are used to treat the pain in a variety of chronic (longterm) conditions without taking regular painkillers.

Question: I have been to a neurologist and he has told me I should stop taking any painkillers or my headache will not get better. How can I do that?

Answer: The ‘how’ depends on what you feel you need to do to stop. We all lead busy, complex lives and have different worries, pressures and concerns, and we try to balance a host of demands on us. Don’t be afraid to ask for help from friends and family. It may be that you will need time off work, so go and see your family doctor or talk to your boss, or both! The only way to succeed is to plan carefully, choose the right time and take small steps so that you can stop for long enough to help the headaches get better.

Question: I have just seen my GP, who has told me my painkillers might be causing my headaches. How will I manage if I stop them?

Answer: If you can stop taking the painkillers, your medication overuse headache will get better. It is one of those contradictions, as you can confirm the diagnosis only if you stop the painkillers … but you don’t want to stop the painkillers in case the headache does not get better. If the diagnosis is right, you will get fewer headaches and the ones that you do get will respond better to the treatment you use. You and your family doctor need to think about other options during this withdrawal or washout phase, that are not painkillers but will help treat your symptoms. A variety of drugs are used to manage chronic pain that will reduce the frequency and severity of your headache symptoms. This might be a short-, medium- or long-term option.

Question: I have been told I have to stop my painkillers. I think I can do that provided I have some time off work. What should I do?

Answer: If you explain to your family doctor what you need to do, you should be able to get a sick note to cover the time off you need. It is difficult to predict how long it will take but you should probably plan on two to three weeks. It may be that you need a little less or a little more time. I am planning to stop taking painkillers for my headaches, and the nurse told me that my headaches may get worse.

Question: What can I do about this and might I get any other symptoms?

Answer: Yes, the headache will often get worse before it gets better in this situation but stopping the painkillers is the only way to make the diagnosis. The symptoms you get when stopping painkillers can vary dramatically from person to person. They may also vary depending on which mix of painkillers you have been taking. You can probably expect to feel sick and sometimes vomit. It is not unusual to experience mood swings and irritability. Some people have disturbed sleep as well.

Question: My family doctor gave me a triptan to treat my migraine. It used to work really well but now my headache seems to be lasting longer and seems to be coming back most days. Why is that?

 Answer: Triptans can cause a medication overuse headache (MOH) in the same way that any other painkiller can. A triptan is just another headache treatment in that sense. Your headache may be a triptan rebound headache, and it will often recur at the same sort of time every day.

Question: You don’t say exactly how often you get your headache: is it more or fewer than 15 days in each month?

Answer: If you are using more than eight to ten triptans a month, it is possible that, even if you don’t have a triptan rebound headache now, if you carry on at this sort of dose level, you will have one in the not too distant future. The question to ask yourself is ‘How many triptans am I taking each month?’; if the answer is more than 10 or 12, you probably have a triptan rebound headache.

Question: My family doctor has said that I can’t have more than six sumatriptan tablets on each prescription, but I use those up in 10 days. What can I do?

Answer: Your family doctor has a point in limiting your triptans to just six on each prescription as that way he can monitor how many you use. If you take too many, you run the risk of developing a triptan rebound headache or medication overuse headache (MOH). If you used only six in a whole month, there would be less of a problem. But you say you are using six every 10 days, so you need to be thinking about whether you are using too many and seek further help. Talk to your family doctor about your difficulty and work out a way to minimize the number of tablets you have to take.

Question: How do I know if I am using too many triptans?

Answer: I take one to get rid of the headache as soon as it starts. The headache gets better but comes back the next day, so I repeat the dose then.  Is that too many? If you are getting one attack a month, you are not using too many. If, however, you are getting one attack every week, you might be using too many. If you are using eight to ten triptans every month, you are at risk of the headaches getting more frequent as a result of the medication. If you are using 12 or more each month, it is even more likely that the tablets are contributing to the problem and you are developing a triptan rebound headache.  Talk to your doctor about how often the headaches come back and, together; you should be able to solve the problem.

 3.3 Cluster Headache and other Trigeminal Autonomic Cephalalgias

Trigeminal autonomic cephalalgias (TACs) are a separate section within the International

Headache Society classification and represent four different headache types:

• Cluster headache, in an episodic or chronic form

• Paroxysmal hemicrania in an episodic or chronic form

• Short-lasting unilateral neuralgiform headache

• Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)

Question: I’m not sure whether my headache is a migraine or a cluster type. How can I tell?

Answer: Migraine is a headache that stops you being able to do things. Migraine makes you want to keep still. Cluster headache, which can be as severe if not more severe than migraine, tends to stop you doing things but you will pace about because you cannot keep still.

Question:   I get this really bad pain several times a night. It is so bad I have to get up and pace about – I just can’t keep still. What could it be?

Answer: It is possible that you are experiencing a bout of cluster headache. Cluster headache pain is very definitely one-sided and tends to make the sufferer agitated, unlike in migraine where the sufferer chooses to keep still. Cluster headache is associated with other symptoms, including reddening and watering of the eye on the same side as the pain. The eye can become swollen and sometimes close a little. You may also get a runny nose on the same side as the pain or it may feel blocked.  Cluster headache lasts for 15 to 180 minutes whereas SUNCT lasts for only 5 to 240 seconds. Cluster headache will occur up to 8 times a day, whereas SUNCT occurs between 3 and 200 times a day.

Question: I get a really bad headache that sits around my eye. Is this migraine or, as my family doctor suggested, cluster headache?

Answer: In order to answer this question I need more information:

• Is your headache always just around your eye, or does it spread further?

• Is your headache always just on one side, or does it spread to both sides?

• Does your eye go red and water on the same side as the headache?

• Is the pain a severe and intense stabbing pain, as opposed to a throbbing, pounding pain?

• Does your nose run or feel blocked on the same side as the pain?

A ‘Yes’ to some or all of these makes cluster headache more likely than migraine.

I also need to know how long the pain lasts and how often you get the pain each day. These two pieces of information will help determine exactly which headache you might have.

Question: Every time I get this pain around my eye, it goes red and waters. It is really weird as my nose feels blocked as well. I could understand it if I was doing something that would make my eyes water, but it just comes out of the blue, and it is only on one side. What could it be? My family doctor is not sure and is sending me to see a specialist.

Answer: It sounds like cluster headache, but it could be any one of the four TACs listed above. They are not particularly common conditions and it is possible that your family doctor has not seen a patient with them before. Because it can be difficult to treat, sending you to a headache specialist is a good idea.

Question: I get this pain that always affects my left eye, and sometimes it spreads to my forehead and temple. My eye waters and can close. I just want to bang my head when I get this pain it is so bad. What could be causing it?

Answer: Cluster headache is the most likely diagnosis, but I need to know how long the pain lasts to be absolutely sure. What causes it, though, is slightly more complex. During a cluster attack, changes occur in a very specific part of the brain called the posterior hypothalamic grey matter. There is no doubt that this is part of the process of cluster headache but what actually triggers, or sets off, each attack is still not absolutely certain.

Question: I get cluster headache that lasts for a few weeks at a time. Could it last longer than it does now?

Answer: The simple answer to that is ‘Yes, possibly’. Episodic cluster headache usually occurs for several weeks, often up to three months at a time. The International Headache Society (IHS) classification states that cluster periods last for anywhere from 7 to 365 days and are separated by a pain-free period of at least a month. The length of each period or episode of cluster is often typical and they tend to be similar, but this is by no means the rule. The length of your period of cluster can change for no apparent reason. You can also swap from episodic to chronic cluster and back again.

Question: I have had cluster headache since I was in my early 20s. It seems to be lasting longer now that I am older – is that normal?

The answer is ‘Yes’, but which bit is lasting longer? Each bout of pain during a period of cluster can last from 15 minutes up to 180 minutes. Each period of cluster can last for several weeks or months. Either way, though, any variation between these parameters is normal.

Question: I used to get my cluster headache every spring but it now seems to come in the autumn as well. Should I be worried?

Answer: No, because the frequency and periodicity of your episodes of cluster can vary for any number of reasons. The IHS suggests that you must have a gap of at least one month between episodes. There is no limit to the number of episodes you can have. You just need to be tuned in to potential triggers to reduce the chance of an episode of cluster being set off.

Question: My last bout of cluster headache just did not seem to want to stop. It usually lasts for only three months, so why did it seem to go on this time?

Answer: That is difficult to say. The length of any period of cluster can vary. There is no particular reason for that bout to have been more prolonged but neither is there any reason why it should not last longer. Unfortunately, 10–15% of patients with cluster headache have chronic cluster headache without any break in symptoms. It may be that there was one of several reasons within your diet or lifestyle that could have led to an extension of your symptoms on this occasion.

Question: I have just been told that I have chronic cluster headache. What is the difference between chronic and episodic cluster headache?

Answer: In simple terms, episodic cluster headache occurs in short but repeated bouts, but chronic cluster headache tends to occur for longer than a year without any breaks or with a break of less than one month.

Question: In some attacks my headache lasts for 15 minutes but in other attacks it seems to last for an hour. Is that normal?

Answer: Yes, the length of time the pain lasts can vary from attack to attack. It should last at least 15 minutes and no longer than 180 minutes to fulfill the IHS classification.

Question: My best friend has just been told that she has SUNCT. What is SUNCT?

Answer: SUNCT – the acronym for ‘short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing’ – is a headache that lasts for only seconds and occurs between 3 and 240 times every day. The eye on the affected side tends to go very red and may water a lot. SUNCT is a type of headache that has become more recognized over the last decade but is very rare.

Question: My cousin has cluster headache and his attacks last nearly three hours but mine never last longer than half an hour. Why is that?

Answer: How long the pain lasts can vary from person to person and from attack to attack. You are each showing duration consistent with the diagnosis of cluster headache. If the headache lasted for less than 15 minutes or longer than four hours the diagnosis might need to be reviewed according to the IHS criteria. If it is very short-lived, it could be SUNCT; if it is longer than four hours, it might be migraine.

Question: Sometimes I get my cluster pain four or five times in the day and sometimes I don’t get any for a day or two, when it seems to come back with a vengeance. Why is that?

Answer: The pain of cluster headache can vary in frequency from day to day, as well as from episode to episode. The variability is unpredictable but this is normal. It is the unpredictability that can be frustrating!

In the same way, the severity and intensity of the pain can vary from attack to attack and from episode to episode. There will be times when the pain will be excruciating and potentially more difficult to treat.

Question: My family doctor says that I have cluster migraine. What does he mean?

Answer: Cluster migraine is not a formal IHS diagnosis. It is difficult to know exactly what your family doctor means when using this phrase. It may be that he means your migraine headaches are coming together in groups or ‘clusters’ or it may mean that he thinks you actually have cluster headache.

Deciding which you have will depend on what other symptoms you experience at the time that you get your headache. If you get a red, watery eye and a runny or blocked nose and the pain is so severe you cannot keep still, it is likely that you have cluster headache. If you have a severe headache that makes you feel sick and you vomit and have to keep still or the pain gets worse when you move about, it is likely that you have migraine.

Question: My son has cluster headache. I understand that it runs in families so can my daughter expect to get it?

Answer: Men are three to four times more likely than women to be affected with cluster headache. So your daughter could develop it but the risk is lower than if you had another son. Cluster headache may be inherited in 5% of cases.

Question: My brother has cluster headache. Could I get it, too?

Answer: If you are male, the answer is yes. If you are female, it is less likely but still possible. Cluster headache is inherited in 5% of cases.

Question: I’ve found that my cluster headache comes on after I’ve been out drinking with my mates. Will avoiding alcohol stop my next cluster attack from happening?

Answer: It is possible but by no means guaranteed that avoiding a bout of binge drinking could reduce the chance of triggering a period of cluster headache. If there are other potential triggers around, think about how these triggers come together. If moderating your volume of alcohol intake, especially at times of change, reduces the chance of cluster headache starting, it must be worth thinking about!

 Question: From what I’ve read on the internet, the pain  I get seems like cluster headache but it only lasts for a few minutes and no longer than 30 minutes. Is it really cluster headache?

Answer: If you are female and the pain never lasts longer than 30 minutes, you get a red watery eye, and possibly a blocked or runny nose as well as some of the other cluster headache symptoms, you may have a condition called paroxysmal hemicrania. The only way for your doctor to make a definite diagnosis is for you to take a course of indometacin. Paroxysmal hemicrania is called an ‘indometacin-responsive’ headache because the headache gets better with a course of indometacin. If your headache does not respond, it is not paroxysmal hemicrania but may be cluster headache. You should see your family doctor to determine whether this is the case; she may suggest referring you to a neurologist or headache specialist for assessment, as it can be difficult to make a diagnosis. Sometimes it is just not possible to slot every headache into a ‘diagnostic box’.

Question: I seem to get bouts of pain for several weeks at a time. My specialist has told me I have paroxysmal hemicrania. My family doctor thought it was cluster headache, so how do they differ?

 Answer: The main differences are that paroxysmal hemicrania is more common in women and always responds to indometacin. In many other ways, though, the symptoms associated with the headache are very similar.

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