Graphique de Localisation du Mal de Tête

Most headaches fall into three primary patterns that can be told apart by location, duration and what makes them worse. Getting the pattern right matters because the treatments differ: what aborts a migraine does little for a tension-type headache, and cluster headache responds to interventions that are useless for either. Separately, and more urgently, a small set of features distinguishes a primary headache from one with a dangerous cause.

Red flags: headaches that need urgent assessment

This comes first because it is the only part of the page that is time-critical. The features below suggest a secondary cause such as haemorrhage, meningitis, raised intracranial pressure or giant cell arteritis, and warrant emergency assessment rather than treatment at home.

• Thunderclap onset: maximum intensity within about a minute, classically described as the worst headache of your life. This is a subarachnoid haemorrhage until proven otherwise.
• Headache with fever, neck stiffness or a rash that does not blanch under pressure.
• New neurological signs: weakness, numbness, slurred speech, double vision, confusion or seizure.
• Headache after head injury, particularly with vomiting or drowsiness.
• A new headache that is consistently worse lying flat, on waking, or on coughing, straining or bending.
• New headache after age 50, especially with scalp tenderness, jaw pain on chewing or visual loss, which suggests giant cell arteritis.
• A headache pattern that has clearly changed in character, or a new headache in pregnancy, in immunosuppression, or with a history of cancer.

Telling the three primary headaches apart

The features below follow the International Classification of Headache Disorders. Real presentations overlap, and many people have more than one type, but the combination of location, duration and effect of movement separates them in most cases.

• The single most useful discriminator between migraine and tension-type headache is whether routine physical activity makes it worse. Migraine typically does; tension-type typically does not.
• Cluster headache is distinctive for restlessness. People with migraine want to lie still in the dark; people in a cluster attack pace.

Medication overuse headache

A headache pattern that has become more frequent over months, in someone taking acute painkillers on many days, may be sustained by the treatment itself. The classification defines it as headache on 15 or more days a month in someone with a pre-existing headache disorder who has been using acute medication regularly for more than three months.

The thresholds differ by drug class: 15 or more days a month for simple analgesics such as paracetamol or NSAIDs, and 10 or more days a month for triptans, ergots, opioids or combination analgesics. It is common, frequently missed, and improves on withdrawal of the overused medication, which is usually best done with medical support because headaches worsen before they settle.

Limites

• This chart describes typical patterns. Presentations overlap, and a substantial number of people have both migraine and tension-type headache, which makes self-classification unreliable.
• A headache diary recording timing, duration, associated features and medication use gives a clinician far more than any single description, and is what diagnosis normally rests on.
• The red flag list is not exhaustive. Any headache that feels different from your usual pattern deserves assessment regardless of whether it appears above.
• Headache in children, in pregnancy, and in people over 50 with a new pattern follows different diagnostic considerations than the general adult picture described here.
• No chart can exclude a secondary cause. Imaging and examination are what rule out the conditions the red flags point to.
• This is general information and cannot diagnose the cause of any individual headache.

Questions fréquentes

How do I tell a migraine from a tension headache?

The most useful single question is whether routine activity makes it worse. Migraine typically worsens with movement and is one-sided, throbbing, and accompanied by nausea or light sensitivity. Tension-type headache is usually a band-like pressure on both sides that is not worsened by activity.

What headache symptoms mean I should go to hospital?

Sudden thunderclap onset reaching maximum intensity within a minute, headache with fever and neck stiffness, any new neurological sign such as weakness or slurred speech, headache after head injury, or a new headache after age 50 with scalp tenderness or visual loss.

How long does a cluster headache last?

Individual attacks last 15 to 180 minutes untreated and often recur at the same time each day, frequently at night, in bouts lasting weeks to months. The pain is strictly one-sided with tearing, a red eye or a blocked nostril on the same side.

Can painkillers cause headaches?

Yes. Medication overuse headache is defined as headache on 15 or more days a month in someone using acute medication regularly for more than three months. The threshold is 15 days a month for simple analgesics and 10 days for triptans, ergots, opioids or combination products.

Does headache location tell you the cause?

Only partly. Location is one of several features and is most useful in combination with duration, quality and associated symptoms. One-sided pain around the eye with tearing points to cluster headache; band-like pressure on both sides points to tension-type. Location alone is not diagnostic.

Références

1. International Headache Society. International Classification of Headache Disorders, 3rd edition (ICHD-3).
2. National Institute of Neurological Disorders and Stroke. Headache.
3. Hainer BL, Matheson EM. Acute Headache. StatPearls, NCBI Bookshelf.
4. MedlinePlus. Headache.