Q 2.33. Primary headache: migraine, tension- type and cluster headache. Primary vs Secondary headaches

Headaches, a prevalent health concern, involve pain or discomfort situated in the head, face, or upper neck. They affect individuals across all demographics and can vary in intensity from mild to severe. The frequency, location, and severity of pain differ based on the specific type of headache experienced.

Headaches are categorized as either primary or secondary.

Primary headaches encompass a variety of conditions that induce episodic or chronic head pain without an underlying pathologic process, disease, or traumatic injury. Chemical activity in the brain, nerves, blood vessels surrounding the skull, or muscles of the head and neck may contribute to primary headaches. Also, lifestyle factors like specific dietary choices, alcohol consumption, stress levels, inadequate sleep, or improper posture can act as triggers for these headaches as much as genetic predispositions.

The main primary headaches are migraine, tension headache, cluster headache, and trigeminal autonomic cephalalgia. Each type has its own symptoms and triggers. Although these headaches are usually not a sign of a bigger health problem, they could sometimes be related to other issues that need attention.

Secondary headaches, on the other hand, stem from an underlying medical condition and serve as symptoms or indicators of an underlying issue. While secondary headaches are relatively rare, they can be significantly more serious than primary headaches and require prompt attention.

Various factors can trigger secondary headaches, including head or neck trauma, sinus infections, allergies, hypertension, tumors, aneurysms, certain medications, meningitis, or stroke.

They can be classified into two categories: those that resolve once the underlying condition is addressed and those indicative of a severe or potentially life-threatening condition.

These headaches can manifest abruptly and often with intense pain. Spinal headaches, thunderclap headaches, and other secondary headache types necessitate immediate medical attention due to the potential for serious complications.



A migraine is a strong headache that causes throbbing pain on one side of your head. This headache can last for hours or even days. It happens because nerves in the walls of blood vessels in your brain become active, triggering the pain.


Migraines happen in four phases:

Premonitory phase: This happens up to a day before the headache.

Individuals may experience

  • mood changes
  • frequent yawning
  • fluid retention
  • difficulty concentrating
  • increase urination

Aura phase: Can occur 5-60 minutes before or during a headache attack. Symptoms usually begins gradually

  • flashing lights/bright spots
  • pins and needles sensation in arm/leg
  • weakness and numbness in the face or one side of the body
  • difficulty of speaking

Headache phase: The migraine starts slowly and gets worse over time. The pain can be transmitted from one side to the other and can last from 4 hours until more than 3 days in severe cases.

  • Nausea and vomiting
  • Severe, one sided headache but can be also on both sides 
  • Sensitivity to light, sounds

Postdrome phase: This phase can last up to a day before starting feeling better.

  • Fatigue
  • Neck stiffness


Treatment for migraines aims to alleviate symptoms during an attack and prevent future occurrences. Various medications are available to address migraines, falling into two main categories: 

Pain-relieving medications: These are taken at the onset of a migraine attack to halt symptoms.

Preventive medications: Taken regularly to reduce the severity or frequency of migraines.

The choice of treatment depends on factors such as the frequency and intensity of headaches, presence of associated symptoms like nausea and vomiting, the level of impairment caused by headaches, and other underlying medical conditions.

Medications for symptom relief work most effectively when taken at the earliest signs of a migraine. These may include:

Pain relievers: Over-the-counter or prescription drugs like aspirin or ibuprofen or other non-steroidal anti-inflammatory drugs. Prolonged use of these medications may lead to medication-overuse headaches and potential gastrointestinal issues.

Migraine relief medications containing caffeine and aspirin can provide relief for mild migraine pain.

Triptans: Prescription drugs available in various forms like pills, shots, or nasal sprays, act by blocking pain pathways in the brain. However, they may not be suitable for individuals at risk of stroke or heart attack.

Dihydroergotamine: Administered via nasal spray or injection, this medication is effective for migraines lasting longer than 24 hours when taken promptly at the onset of symptoms. It may worsen migraine-related vomiting and nausea and is contraindicated in individuals with coronary artery disease, high blood pressure, or kidney or liver disease.


Tension-type headache

Tension-type headaches (TTH) is the most common type of headache and is often described as a feeling of pressure or tightness occasionally radiating from or towards the neck. They may be linked to stress or issues with the muscles and bones in the neck. These headaches commonly begin during adolescence and are more prevalent among women, outnumbering men by 50%.

In contrast to migraines, tension type headaches don’t cause symptoms like sensitivity to light or noise, vomiting or nausea or other nerve symptoms like blurred vision.

Episodic tension headaches
Can occur less than 15 days per month and can last from 30 minutes to a few days.

Chronic tension headaches
Can occur more than 15 days per month and may be constant


  • dull head pain
  • mild to moderate pain or pressure
  • tightness on the forehead or on the sides and back of the head
  • Tenderness


Pain relievers: Over-the-counter pain relievers like aspirin, ibuprofen, and naproxen sodium are commonly used to alleviate headache pain.

Combination medicines: These medications may contain aspirin, acetaminophen, or both, combined with caffeine or a sedative. They are available without a prescription and can be more effective than single-ingredient pain relievers. In general combinations should be avoided.

Triptans: For individuals experiencing both migraines and episodic tension-type headaches, triptans can effectively relieve pain.

For individuals with chronic tension-type headaches, treatment goals involve initiating effective preventive treatment and managing residual headaches to prevent frequent analgesic use and progression to chronic daily headache syndrome. Limiting analgesic use to twice weekly is recommended to prevent chronic daily headache development. If needed, adjunctive headache medications such as sedating antihistamines or antiemetics can be considered.


Cluster headaches

Cluster headache (CH) is a type of primary headache disorder characterized by frequent, intense headaches that occur several times a day. These headaches are typically very severe and focus around one eye. They are often accompanied by tearing and redness of the eye, as well as a runny or blocked nose on the affected side. Additionally, the episode usually last between 15 to 3 hours.

Cluster headache can be:
Episodic: Episodic cluster headaches occur in cycles, with periods of frequent attacks followed by remission periods that may last months or even years. The majority of cluster periods typically range from 14 days to 12 weeks in duration, up to 100 attacks per day.

Chronic: Continuous episodes lasting over a year without relief, or periods of relief lasting less than three months. Up to 20% of individuals experiencing cluster headaches have what’s known as chronic cluster headache.


  • sharp/stabbing pain behind or around the eyes on one side
  • forehead/facial sweating/flushing
  • redness of the eye
  • watery eyes
  • droopy eyelid


Treatment for cluster headaches requires a dual strategy aimed at halting ongoing attacks and preventing future occurrences.

Cluster headache medications are categorized into two types, each serving distinct purposes:

Preventive medications: These medications aim to shorten the duration of a headache cycle and reduce the severity of headaches. Common medications may include those used for allergies, depression, hypertension, and seizures.

Pain management medications: During a headache episode, certain medications may alleviate symptoms, such as triptan medications or anti-inflammatory medications (steroids). Inhalation of 100% oxygen may also provide relief during an attack.

Anti-inflammatory medications (NSAIDs like ibuprofen) are not effective for treating cluster headaches.


Types of primary headache





Intense throbbing pain (unilateral)

Nausea, vomiting, sensitivity to light and sound, difficulty concentrating

Stress, hormonal changes

Tension headache

Dull, constant pain (both sides). Tightness on the forehead or on the sides and back of the head

Mild to moderate pain, no nausea/ vomiting

Stress, poor posture, eye strain

Cluster headache

Severe sharp pain (one eye)

Severe pain behind or around eye, nasal congestion, eye redness, flushing/ facial sweating

Alcohol, strong odors, changes in sleep patterns


PubMed: Primary Headaches https://pubmed.ncbi.nlm.nih.gov/30189986/

ClevelandClinic: Headaches: https://my.clevelandclinic.org/health/diseases/9639-headaches

hoag: Primary Headaches: https://www.hoag.org/specialties-services/neurosciences/programs/headache/types-of-head ache/primary-headache/

MayoClinic: Headache: https://www.mayoclinic.org/symptoms/headache/basics/causes/sym-20050800

Stanford Medicine: Types of headache: https://stanfordhealthcare.org/medical-conditions/brain-and-nerves/headache/types.html

World Health Organization: Migraine and other headache disorders: https://www.who.int/news-room/fact-sheets/detail/headache-disorders

Mayo clinic: Migraine: https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-2 0360201

Cleveland clinic: migraine headaches: https://my.clevelandclinic.org/health/diseases/5005-migraine-headaches

WebMD: What is Migraine?: https://www.webmd.com/migraines-headaches/migraines-headaches-migraines NIH: Migraine: https://www.ninds.nih.gov/health-information/disorders/migraine

WebMD: Tension Headaches: https://www.webmd.com/migraines-headaches/tension-headaches MedlinePlus: https://medlineplus.gov/ency/article/000797.htm

the migraine trust: cluster headache: https://migrainetrust.org/understand-migraine/types-of-migraine/other-headache-disorders/cl uster-headache/

Verified by Dr. Petya Stefanova