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Headache Worries

Headache is one of the most common patient complaints heard inside of a neurology office.

The overwhelming majority of headaches are “Primary Headaches" such as migraine headaches or tension type headaches. While these forms of headache are painful and at times debilitating, they are ultimately benign, meaning they pose no danger to one’s overall health.

Despite this fact, a great number of patients worry that their headache is a "Secondary Headache" – defined as a headache with a serious or even life-threatening underlying cause. As such, the important question is this: When are neurologists concerned that a headache isn't just a headache?

Jeffrey Greenberg, M.D., Neurology Division Chief at Saint Peter’s University Hospital in New Brunswick, N.J., is here to answer that question.

Headache Worries
Jeffery Greenberg, MD
Dr. Greenberg completed his neurology residency and fellowship at Albert Einstein College of Medicine in New York City. He has been in a very busy private practice in central New Jersey since 2003. In addition to patient care, Dr. Greenberg also enjoys running clinical trials and teaching medical student and residents.

For more information about Saint Peter’s Healthcare System

Bill Klaproth (Host): Headache is one of the most common patient complaints heard inside a neurology office, and the overwhelming majority of headaches are primary headaches such as migraine headaches or tension-type headaches. While these forms of headaches are painful and at times debilitating, they are ultimately benign—meaning, they pose no danger to one’s overall health. But, when should you be concerned and when are neurologists concerned that a headache isn’t just a headache? We are pleased to have Dr. Jeffrey Greenberg, neurology division chief at Saint Peter’s University Hospital, with us today. Dr. Greenberg, thank you so much for sharing your time today. So, what are the most common headache types you see in the clinical practice of adult neurology?

Dr. Jeffrey Greenberg (Guest): Bill, thank you for having me. Again, the most common headache types of all under the category of primary headache disorders, these are the headaches, as you said, that can be quite painful and debilitating but there’s really no underlying pathology or problem that’s going to endanger the patient or the patient’s health. The most common primary headaches we see are, of course, migraine headaches, with or without aura; tension-type headaches, which is your common headache that occurs to you at home for a few hours and relieve with Tylenol. And then there’s a potpourri of some less common headaches that we see that are also primary headaches, such as cluster headache, exertional headache, cough headache, and paroxysmal hemi-crania, to name a few.

Bill: Okay. So, the most common type of headache is a primary headache. What would you call an uncommon type of headache? What is the terminology for that?

Dr. Greenberg: Well, the main stress today, Bill, that I’d like to emphasize is primary versus secondary headache.

Bill: Okay. So, the uncommon ones are kind of the secondary headaches?

Dr. Greenberg: Right. That’s correct. Far less common than primary headaches are secondary headaches, and those are the headaches that the patients worry that they have. Let’s talk about the secondary headaches—headaches that are secondary to an underlying, either brain, or systemic or, in other words, a body problem. I’d like to give you a few examples of these—and this is an abridged version—but some examples…

Bill: Absolutely.

Dr. Greenberg: Okay. Fantastic. Some examples of secondary headache would be headaches associated with head trauma; headaches associated with blood vessel malformations—sometimes rupture and an aneurysm, for example—headaches associated with brain tumors; infections of the brain or the covering of the brain called meninges; differences in pressure of the cerebrospinal fluid. That’s the fluid that bathes the brain and spinal cord. If that pressure goes up or down, that can relate to headache. And then there’s exposure to various viral or bacterial issues and medications, and also substances. Those would be some examples of secondary headaches.

Bill: How often do those things happen? Obviously, head trauma’s a random thing, but blood vessel malformation, brain tumor, infections, spinal pressure, how often does that happen compared to regular primary headaches?

Dr. Greenberg: Right. That’s a great question, Bill. I’ve been in clinical practice for 11 years. I’ve seen thousands and thousands of headache patients, and the secondary headaches are really quite rare in my experience. Let’s take brain tumors, for example. That’s the feared diagnosis that many people have when they come into the office or the hospital. It’s true that about 50 percent of patients with a brain tumor will have a headache associated with it, often a tension-type or migraine-type headache, or seemingly one of those. But the fact of the matter is that brain tumors are quite rare, in my general experience, and account for only a small portion of all headaches that we see.

Bill: Okay. Is there a red flag then in a headache? I know this may be a silly question, but is there one that you see that is associated with one of the secondary causes that can lead you to say, “Oh boy, this is not a primary headache. This could be of the secondary nature”? Because it lasts longer or is more intense?

Dr. Greenberg: I’d be happy to talk about a few of those. Before I talk about the red flags -- and when I say “red flags,” I mean things that capture and pique our attention as neurologists to really strongly consider the possibility of a secondary headache disorder. What gets us to sit up and really concern ourselves with that particular headache? Before I get into that, I do want to emphasize that the neurological history is of utmost important. About 85 percent of neurological diagnoses are made by history. We would ask the patient if it’s a first or worst headache, how bad that headache pain is; is the headache different from the usual headache; what the symptoms are during the headache and now; characterize the pain, when I look at the medications and medical problems the patient has; and also, importantly, the tempo of the headache. Those are some of the questions we would be asking in the history to try to start to think about whether this is a secondary headache. Now, in terms of what really stands out for us, the buzzwords “first” and “worst” really come to mind. The first headache of your life, especially if you’re an older adult, with the worst headache of your life, especially if it’s come on rather suddenly, these are things that really concern us and alert us to the possibility of a secondary headache. Headaches that increase in frequency and severity over time, that’s a concern. Another red flag would be headaches in patients who have HIV or risk factors for HIV or cancer. Headaches associated with signs of systemic illness, such as fever, stiff neck, or rash. Headaches that are associated with focal neurological signs. And that’s something I’ll talk about in a few moments when I talk about the neurological examination and signs in a finding on the examination. We worry when we see things like optic disc edema. That’s swelling of the optic nerve head, and that can represent or be indicative of raised pressure within the cranium. And also, of course, headache subsequent to head trauma can be of concern. So those are the red flags that make myself and other neurologists sit up and say, “Let’s look into this very closely and not miss a secondary headache.”

Bill: That’s excellent, excellent information. For our listener right now, if one of those things is happening to them or, like you just described, that would be reason to call the neurologist and set up an appointment, because that may not just be a regular primary headache then.

Dr. Greenberg: That’s correct. In fact, often, when we think of secondary headaches -- that’s a correct statement. Still, if you have these things, they still often turn out to be primary headaches but we have to rule out secondary headache processes. These are the things that make us think to do that more strongly.

Bill: Okay. So, you were going to talk about the examination process. Why don’t you tell us about that right now?

Dr. Greenberg: Sure, I’ll be happy to. I wanted to highlight several of these red flags, and just in the interest of time, I’ve chosen three.

Bill: Okay.

Dr. Greenberg: The first one I’d like to highlight -- if that’s okay with you, Bill.

Bill: Absolutely.

Dr. Greenberg: Okay. So the first one I’d like to highlight is a patient that comes in with a headache. We take the history, as I mentioned before, and we do a neurological examination. Those listeners out there who have not had a neurological examination, it’s a little bit unusual. It’s unlike your regular medical exam. We watch you walk; we check your balance, strength, reflexes; we check muscle tone; we look at coordination; we look at the eyes, mouth, face, and so forth. That’s the cranial nerve examination. We do some other things such as watching how you move your fingers, take your finger and move from your nose to the examiner’s finger. That’s all coordination issues, in addition to strength and sensation. If we find something on the exam that looks abnormal and shouldn’t be there—for example, weakness on one side of the body, abnormal sensation outside of the body, an abnormal walk, a visual field cut, not being able to see out of one field of vision—these are signs, things that we see on the exam that the patient themselves may not be aware of. Sometimes it’s subtle, and that will alert us and say, “Listen, let’s focus in on that specific area of the brain that controls that function. And if that’s in conjunction with a headache, that’s a red flag for us. There may be something underlying within the brain itself. May I go on with two other red flags which I’d like to highlight for the listeners?

Bill: Absolutely. Why don’t we close out with those two last red flags?

Dr. Greenberg: Fantastic. Again, I want to go back to the buzzwords of “first” and “worst.” When I talk about first headache, I’m talking mostly about those in the older folks. If an older person—let’s say, above 60—has a new headache and they have, for example, pain when they chew, scalp tenderness, muscle aches and so forth, we have to be concerned about the inflammation of the blood vessels called temporalarteritis. That’s something we must rule out through blood tests, sometimes through biopsy of an artery, and locations of the consequences of missing that or potentially vision loss. We cannot miss that. So, older folks with new headaches, something we take very seriously. Finally, I want to highlight the concept of the sudden, severe headache. This is called the thunderclap headache. The intensity of the headache reaches maximal intensity very, very quickly. I’ve had patients who’ve had these and they described it as if they were walking into a room and they thought somebody hit them at the back of the head with a 2 x 4. That’s how bad it is. Now, that can still be a primary headache, like what we’ll call a crash migraine, which is a migraine variant. But, to any neurologist out there, that’s a very alarming story, and until we prove otherwise, we are very, very concerned about a number of secondary headache disorders, foremost of which is rupture of an aneurysm leading to bleeding in the gyri or crevices of the brain. That’s a neurological/neurosurgical emergency that needs to be addressed right away because there’s a high mortality and even morbidity rate.

Bill: Gotcha. Great. Great information for anybody that’s suffering from a headache. Just one quick last question. For somebody who does have a headache and they come to you and say, “When should I see the doctor?” in general, is there an easy statement to say when you should go see a doctor if you’re concerned about a headache?

Dr. Greenberg: I’m sorry, Bill. So, if a patient asks their internist for example, when they should see the neurologist?

Bill: Yeah. Or somebody just thinking to themselves, “Boy, I’ve got this headache,” or, “I’ve had these headaches for a while. Maybe I should go see a neurologist.” What would you say to that person? When should somebody go see a neurologist?

Dr. Greenberg: I think if it’s a matter of a person having some headache problems for a number of years and things haven’t really changed much—there’s nothing new, it’s not worsening, there’s no change in headache pattern—chances are, that’s not a secondary headache. Chances are it’s a primary headache. Unless their primary physician steers them, see something or hear something that makes them feel strongly they should see a neurologist, they don’t necessarily have to. But they certainly can if they want to because people are always concerned about secondary headaches. But I would say if there’s a first or worst headache, if there’s a change in your headache pattern or there’s other things going on in your medical life—a new infection, a new medical condition, so on and so forth—that would be things that would prompt me to recommend that they be evaluated by a neurologist.

Bill: All right. Very good information, Dr. Greenberg. Thank you so much. I really appreciate your time today. For more information on Saint Peter’s, please visit This is Saint Peter’s Better Health Update. I’m Bill Klaproth. Thanks for listening.