With regard to characteristic temporal patterns, migraine of the typical type usually has its onset in the early morning hours or in the daytime, reaches its peak of severity over several to 30 min, and lasts, unless treated, for 4 to 24 h, occasionally longer. Often, it is terminated by sleep. A migrainous patient having several attacks per week usually proves to have a chronic form of migraine or a combination of migraine and analgesic “overuse headache,” meaning that the headache returns when the effect of the drug has worn off, or rarely, some unexpected intracranial lesion. By contrast, cluster headache is characterized by the occurrence of unbearably severe unilateral orbitotemporal pain coming on within 1 or 2 h after falling asleep or at predictable times during the day and recurring nightly or daily for a period of several weeks to months; usually an individual attack of “cluster” dissipates in 30 to 45 min but may occasionally last several hours. The headache of intracranial tumor may appear at any time of the day or night; it may interrupt sleep, vary in intensity, and last a few minutes to hours as the tumor raises intracranial pressure. With posterior fossa masses, the headache tends to be worse in the morning, on awakening. Tension headaches (now called “tension-type headache”) can persist with varying intensity for weeks to months or even longer; when such headaches are protracted, there is often an associated depressive illness. In general, headaches that have recurred regularly for many years prove to be migraine or tension in type.
The relationship of headache to certain biologic events and also to certain precipitating, aggravating, or relieving factors can be of great significance in diagnosis. Headaches that occur regularly in the premenstrual period are usually generalized and mild in degree, but attacks of migraine may also occur at this time (catamenial migraine). Headaches that have their origin in cervical spine disease are most typically intense after a period of inactivity, such as a night’s sleep, and the first movements of the neck are stiff and painful. Headache, or more often face ache, from infection of the nasal sinuses may appear upon awakening or in midmorning and is characteristically worsened by stooping and changes in atmospheric pressure; there is associated midfrontal or maxillary tenderness. Eyestrain after long-sustained periods of reading, or exposure to the glare of video displays, may be associated with head pain but it is transient and not an important cause of headache. In certain individuals, alcohol, intense exercise (such as weight lifting), stooping, straining, coughing, and sexual intercourse are known to initiate a bursting (thunderclap) headache, lasting a few seconds to minutes. If a headache is made worse by sudden movement or by coughing or straining, an intracranial source is tentatively suggested. Migraine often occurs several hours or a day following a period of intense activity and stress (“weekend,” or “letdown” migraine). Some patients have discovered that their migraine is relieved momentarily by gentle compression of the carotid or superficial temporal artery on the painful side, and others report that the carotid near the angle of the jaw is tender during the headache. Pain that is noticed when the scalp is stroked in combing or fixing the hair (allodynia) is common in migraine but could be a symptom of inflammation of the temporal arteries (temporal arteritis). Certain medications, most vasodilators such as nitroglycerin and dipyridamole but also monosodium glutamate, are apt to cause headaches. The headaches that follow a period or excessive alcohol (hangover) or a concussion are well known. In many of these instances, a propensity for migraine may create a susceptibility to an induced headache.