Headaches: when should you see a doctor?

This chapter is excerpted from our new book, AM I DYING?! A Complete Guide to Your Symptoms – and What to Do Next. We review over forty common symptoms using the below format. If you like what you see, pre-order your copy today!

Most of us know that familiar pounding sensation that occurs at the end of a long week, when the coffee is no longer helping, the walls are closing in, and you start looking for the nearest desk to crawl under. A bad headache is often the answer to that nagging question: How can this day get any worse?

But what if this headache is different? What if it’s . . . the big one? What if your boss, your spouse, or your kids finally made that aneurysm burst, just like you always said they would?

Before you panic, let’s pause to review the facts. Many people have experienced headaches severe enough to go to the E.R.; in fact, one in fifty E.R. visits is about headaches. And yet, most of those people survive, and you (probably) will too. As Arnold Schwarzenegger once said: “It’s not a toomah!”

Or is it? Sometimes headaches are the first sign of an underlying medical problem, possibly even a life-threatening one. In addition, many people suffer unnecessarily from recurring headaches that would improve with the correct treatment. So how can you tell if it’s time to get your noggin checked?

Take a Chill Pill

Your headache is mostly in your forehead or face, and you’ve recently had symptoms of a cold, like a fever and runny nose. One of your sinuses is probably jammed with mucus and too swollen to properly drain. You can try to thin out the mucus by inhaling warm vapor. If you’re brave, use a neti pot to directly flush your sinuses. (We recommend not doing this in front of anyone you’d ever like to see again.) Finally, you can take ibuprofen/Advil/Motrin along with a decongestant like pseudoephedrine or phenylephrine, found in products like Sudafed and Dayquil. (You’ll need to show ID, such as a driver’s license, to purchase products containing pseudoephedrine, since sales are limited because it can be converted into crystal methamphetamine, or meth.) If the pain gets steadily worse and lasts for more than a week, you might need antibiotics; make an appointment to see your doctor.

You also have fever, body aches, muscle aches, and a sore throat. You probably have the flu. Unfortunately, even the flu vaccine can’t provide absolute protection from infection. If your symptoms started less than two days ago, you can call your doctor for a prescription of oseltamivir/Tamiflu, which may shorten your illness. (The treatment is less effective if started later.) Otherwise, the best treatment is rest, plenty offluids, and acetaminophen/Tylenol.

You recently kicked your coffee habit. Did you ever think you would be diagnosed as being in “withdrawal”? Well—congratulations! Caffeine is often used to treat headaches, but going cold turkey can actually lead to withdrawal headaches. You’ll need to ride this out, perhaps with the help of a pain reliever, like ibuprofen/Advil/Motrin.

Your headache feels like a band around your skull but gets better with rest and medications like acetaminophen/Tylenol. These symptoms are typical for a tension headache, the most common and least dangerous headache type. The name is spot-on for two reasons. First, it feels like tension or pressure around your head. Second, it’s brought on by tension in your life — like stress and lack of sleep. These headaches don’t require medical attention unless they’re happening often enough to interfere with your life.

The pain is uncomfortable but not intolerable, came on gradually, and isn’t associated with any other symptoms. Some headaches don’t fit any specific pattern but also don’t have any alarming features. Take a pain reliever with a tall glass of water and lie down in a quiet room. Give the medicine at least an hour or two to work. You should feel better soon. If the pain keeps getting worse or becomes more regular, take a look through the next sections.

Make an Appointment

You’re having frequent or intense headaches now, but never used to before. High levels of stress, poor sleep, or a sudden decrease in caffeine intake can cause new-onset headaches in a person who doesn’t normally have them. If there’s no obvious explanation, however, you should see your doctor. Depending on your headache pattern, you may need some tests. People who are older than fifty or have immune compromise (like from HIV infection or chemotherapy) are at higher risk of having a serious problem.

You occasionally have gradual-onset, throbbing headaches along with nausea and increased sensitivity to light and sound. This pattern is classic for migraines. These headaches can be excruciating but are usually not dangerous. Migraines are more common in women than in men, most often starting in your twenties or thirties. The pain is typically (but not always) on just one side of the head. Migraines frequently occur in response to specific triggers, like stress, hunger, strong smells, and even bad weather. Some people experience an aura just before the migraine, which can consist of strange smells, flashing lights, or other warning shots.

If you think you’re having migraines, see a doctor to confirm the diagnosis and get on the right medications. Occasional migraines are usually just treated with acetaminophen/Tylenol or ibuprofen/Advil/ Motrin. It’s important to take these medicines as soon as the headache (or aura) starts, or they’ll be less effective. More frequent or severe attacks require medications like sumatriptan/Imitrex. If you have very frequent migraines, you can (1) officially label yourself a migraineur, part of the world’s least desirable club, and (2) take medications to actually prevent attacks (rather than just treat them).

You feel like someone is periodically hammering a nail into one of your eye sockets. On the same side as the pain, your eye becomes red and swollen, your nose becomes stuffy or runny, and your forehead becomes hot and sweaty. This particular circle of hell, known as a cluster headache, is so unbearable that it has caused some of its victims to commit suicide. (Seriously.) It strikes on a regular basis, sometimes multiple times throughout the day. Don’t even think about trying to manage this problem on your own. Plus, your doctor will likely want you to have a brain scan to check for tumors, which can present with these symptoms.

You’re over fifty, your scalp hurts when you brush your hair, and your jaw gets tired after chewing for a few minutes. You may have a condition known as temporal arteritis, in which the arteries on the side of your face become diseased and narrowed. The major symptoms include headache, scalp tenderness, jaw fatigue after chewing, and vision changes or loss. If the disease isn’t quickly diagnosed and treated, permanent vision loss can occur. See your doctor as soon as possible.

Get to the E.R.

Your speech has also become slurred, or you feel weak or numb in an arm, leg, and/or side of your face. You could be having a stroke, which occurs when the brain is suddenly deprived of blood. Go to the hospital as quickly as possible. As we say in the medical business, “time is brain” when you’re having a stroke. If you make it to the hospital in time, doctors may be able to administer emergency medications to improve blood flow to your brain. (Why are you still reading this? Go to the hospital!)

You’re feeling groggy and not quite right. A headache associated with confusion, excess sleepiness, or personality changes may indicate high pressure around the brain from infection, tumor, or bleeding. Allrequire emergency attention. (If, in contrast, you’re first feeling sleepy for a perfectly normal reason, and then you get a headache, it’s probably just a tension headache and not a cause for alarm.)

You have a fever and your neck also hurts. An infection around the brain, known as meningitis, causes high fevers, headache, and neck stiffness/pain. Some people also become sensitive to bright lights. If you don’t receive prompt treatment with antibiotics, meningitis can cause seizures, coma, and death. It’s also highly contagious, so skip the goodbye kisses as you’re being loaded into the ambulance.

The headache came on fast and furious. Headaches that go from zero to ten within a few minutes are known as thunderclap headaches. They’re often a sign of a serious and rapidly progressing problem, like bleeding into the brain. You’ll need to get to the E.R. for an urgent brain scan.

You hit your head, hard. A head injury followed by a worsening headache may be a sign of a concussion or a life-threatening problem like a brain bleed.

The headache started while you were working out. If you’re trying to impress people at the gym, then suddenly feel like you have an ice pick in your face, it’s possible that the straining burst a blood vessel in your head or neck. If your main source of exercise is jogging to the bathroom during commercial breaks, you may also experience this problem with less intense activities, like running on a treadmill. Because blood around the brain can rapidly spell your demise, you should get to the E.R. for a full assessment right away.

The headache started during or after sex. If you get a new, explosively severe headache during sexual intercourse, you should politely ask for a raincheck, put your clothes back on, and head to the E.R. Just like exercise, sex can burst one of your brain’s blood vessels, causing severe and sudden-onset pain. If you instead note that sex often causes minor, gradual-onset headaches that become worse as you approach climax, you can skip the E.R. but should see your doctor in the next few days. You’ll likely need a brain scan, as tumors and other abnormalities can sometimes cause these symptoms.

Your vision is fading in one or both eyes. Several different conditions can cause headache and blurred vision. Almost all require urgent attention. Increased pressure around the brain can pinch the nerves that connect to the eyes, leading to blurred vision. As described earlier, blockages in the arteries that supply the eyes and skull with blood can cause blurred vision, headache, scalp tenderness (i.e., when combing your hair), and jaw fatigue after chewing. Acute glaucoma (a problem with fluid circulation in the eye) can cause blurred vision, red eye, and severe headache. In rare cases, migraines can also present with vision loss before or during the headache; however, unless you have a known history of such migraines, you should always get an urgent evaluation for any headache associated with vision changes.

Other people in the house are also having headaches for no apparent reason. Did you remember to change the batteries on your carbon monoxide detector? Open the windows and get outside quickly. Carbon monoxide has no odor or color. It can leak from your home’s gas lines, seep in from your garage if a car is running with the door closed, and fill your home if you build a fire but don’t open the chimney. Poisoning causes headache, confusion, nausea, shortness of breath, and eventually death. The treatment is breathing pure oxygen, which accelerates the removal of carbon monoxide from your blood. Severe poisoning requires treatment in a special glass chamber that delivers pure oxygen at very high pressures.

You just used cocaine or methamphetamine. Surely you didn’t think these drugs would improve your health. In fact, they greatly increase the risk of stroke and brain bleeding. If you get a severe headache after using them, get to a hospital right away. Seriously, don’t worry about getting in trouble. Your life is way more important. Besides, most emergency rooms are full of people who are high on drugs. As long as you’re not acting belligerent, or putting others (or your own life) in danger, it is extremely unlikely a doctor would ever get the police involved.

Christopher Kelly, M.D., M.S.

Christopher Rehbeck Kelly, M.D., M.S., is a cardiologist at North Carolina Heart and Vascular and UNC Rex Hospital in Raleigh, North Carolina.

Marc Eisenberg, M.D., F.A.C.C.

Marc Sabin Eisenberg, M.D., F.A.C.C., is an associate professor of medicine at Columbia University Medical Center and an attending cardiologist at NewYork-Presbyterian Hospital.