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When to Worry: Headaches



One of the most common complaints I see in primary care, in both children and adults, are headaches. (Most people don't look quite as glamorous as the stock photo above.) Headaches are tricky because they can be as simple as a tension headache or as complex as a brain tumor, or about 50 other diagnoses in between. If it were as simple as Googling, I wouldn't have needed those 4 years in medical school and subsequent 4 years in residency training.




So what do you do when you're having a headache and you're concerned? I totally understand why people Google their symptoms - we all want answers when we're worried about our health. When you have a direct primary care doctor it's easy enough to call or text your doctor to find out if you should be concerned, but if you belong to a traditional medical practice, it's not so simple. Here's a breakdown of concerning signs and symptoms I look for when I'm evaluating someone with a headache. These are general guidelines, so as always, talk with your doctor if you're concerned about your own headache situation.


1) I'm calling 911.
  • Terrible, worst headache of your life. Now, we're all going to have our worst headache of our life at some point, but if you have a headache that's just so far outside your normal headaches that you wonder if you're dying, don't wait at home to see if you're right. This could be a brain bleed like a subarachnoid hemorrhage.

  • Sudden onset, also known as "thunderclap" headache. If the worst headache of your life hits you like a bolt of lightening, go directly to the ER.

  • Headache with change in speech, weakness, numbness, tingling, loss of consciousness, or vision loss. This could be a stroke. The faster you're evaluated, the better. (Note: some people with migraines have these types of symptoms, but if they're new for you, you still need to be checked out, even if you have a history of migraines.)

  • Headache with high blood pressure. This can also be a sign of a stroke, and is also known as "hypertensive emergency."

Patient story: One of my patients called me directly one day and said he had a terrible headache. It was subtle, but I noticed he was mixing up his words a little bit. I made sure he was at home, and called 911 to pick him up to take him to the ER. He was diagnosed with a hemorrhagic stroke, meaning he had bleeding in his brain that caused his symptoms. Fortunately, he's making a full recovery. I am so thankful he called me and we were able to talk right away, instead of waiting on hold with a call center trying to get advice.


This illustrates how seriously we take warning signs. If you or your family member are ever having a severe headache and any warning signs listed above, do not hesitate to call 911. My patient above was also a little confused due to the stroke, which is why he didn't call himself.





2) I'm worried.
  • You're having worsening headaches.

  • You're experiencing daily headaches.

  • You have a headache with fever. (This could be something as simple as a viral infection or strep throat, but it could be a more serious infection like COVID-19 or meningitis.)

  • You're over 50 years old and have a new type of headache.

  • You had a head injury and have a headache.

  • You wake up in the morning with a headache, or with headache + vomiting.

  • You have headaches when you exercise, have sex, or otherwise exert yourself.

  • You have gradually worsening headaches with vision changes or any other new symptoms. The brain affects almost everything in your body. There are too many concerning symptoms to detail, but when in doubt, you should definitely talk with a doctor about your new symptoms.



3) I feel bad for you, but I'm not panicking.
  • You have a one-sided, throbbing headache with nausea or vomiting. This is a classic story for a migraine headache. So long as it's not too severe, we can typically figure out a good plan for treating these in the office.

  • You have headaches that start in the neck and travel up your head. This is very commonly seen with anxiety and stress. Treating the anxiety usually fixes the headache situation.

  • You have pain on your forehead or both temples. This is the usual story with a tension headache. They're very annoying, and we still need a game plan to prevent and treat these, but this can happen in the office rather than an urgent care or ER.


General Tips to Prevent Headaches:

1. Get plenty of quality sleep.

Sleep is SO important for your health. Often headaches can be the first sign of sleep disorders like sleep apnea in both kids and adults. Snoring can be a sign of obstructive sleep apnea, which commonly causes headaches. The goal is 7+ hours of sleep for an adult, and generally 8-10+ hours for a child. If you don't feel rested when you wake up, that can be a sign of a sleep problem that needs further evaluation.


2. Stay hydrated.

There's no magic number of fluid ounces you should be drinking each day, but you should be drinking water throughout the day. If you're working out or outside in the heat, make sure to bump up your fluid intake.


3. Eat regular, balanced meals.

Prolonged fasting can lead to headaches. Also eating processed foods and certain chemicals, like MSG, can cause more headaches.


4. Manage and prevent stress.

Well, that sounds easy, right? Right...until you're trying to work and your kids' school is closed and they're running around you screaming. (No, just me?) The point is, people with frequent headaches have to be very vigilant about managing their stress to prevent triggering a headache. If you're chronically anxious or depressed, you should talk to your doctor about how best to treat that, which often will fix the headache problem at the same time.



This is a basic list, and almost no two people have the same type of headache, making this a particularly difficult problem to diagnose and treat. Therefore, know that you are NEVER WRONG to choose to get evaluated for headaches. Our job as physicians is to work with you to figure out what is going on, and come up with a game plan to evaluate and treat your problem. We want to help! 😊

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