When Is a Headache More Than Just a Headache?

Headaches are incredibly common. Most of us will experience them at some point, whether from stress, dehydration, lack of sleep, illness or a migraine. And in the vast majority of cases, a headache is not a sign of a serious neurological problem.

But as a neurosurgeon, I am often asked a very understandable question: How do I know when a headache is something I should worry about?

The answer usually isn't based on how uncomfortable a headache is alone. What matters is whether the headache is new or different, how it began, whether it is getting progressively worse, and—most importantly—whether it is accompanied by other neurological symptoms.

Pay Attention to a Headache That Is New or Different

If you have experienced migraines or recurring headaches for years and they continue to follow a familiar pattern, that is very different from suddenly developing a type of headache you have never experienced before.

A change in your usual headache pattern is worth discussing with your physician. That could mean headaches are becoming more frequent, lasting longer, feeling different or no longer responding to the approaches that previously helped.

This does not automatically mean something serious is wrong. It does mean it may be time to understand why the pattern has changed.

Some Headaches Require Immediate Attention

One headache description we take particularly seriously is a sudden, extremely severe headache that reaches maximum intensity very quickly. Patients sometimes describe this as the worst headache of their life.

That type of headache can be associated with bleeding around the brain, including bleeding caused by a ruptured brain aneurysm, and should be treated as a medical emergency.

A severe headache also warrants immediate medical attention when it occurs along with symptoms such as:

• New weakness or numbness

• Difficulty speaking or understanding speech

• Confusion or loss of consciousness

• A seizure

• New problems with vision

• Significant dizziness or loss of balance

• Fever with a stiff neck

• A headache following a significant head injury

In these situations, don't wait for a regular office appointment. Seek emergency medical care.

What About Brain Tumors?

This is another concern I hear frequently. Someone develops headaches and understandably wonders whether a brain tumor could be responsible.

The reassuring news is that headache alone is rarely an indication of a brain tumor.

When a brain tumor does cause headaches, there may be other changes as well, depending on the tumor's size and location. These can include seizures, weakness, problems with balance, changes in vision or speech, or other neurological symptoms.

Brain tumors are also very different from one another. Some grow slowly and can be monitored for a period of time. Others require treatment. Even when a tumor is discovered, surgery is not automatically the first or only option.

That is an important point I try to emphasize with my patients: a diagnosis doesn't necessarily dictate one particular treatment.

When Does a Neurosurgeon Become Involved?

Most people with headaches will never need a neurosurgeon.

Your primary care physician or a neurologist is often the appropriate place to begin when headaches are recurring or changing. Imaging such as an MRI or CT scan may be recommended depending on your symptoms, medical history and examination.

A neurosurgeon may become involved when imaging identifies a structural or vascular problem involving the brain or its blood vessels—for example, a brain tumor, aneurysm or another condition that may require specialized evaluation.

Even then, seeing a neurosurgeon does not necessarily mean you need surgery.

My approach is always to understand the individual patient first. What is causing the problem? What are the risks of treating it? What are the risks of leaving it alone? Is observation appropriate? Is there a minimally invasive option? Is traditional surgery necessary? There are never two patients who are exactly the same, and treatment shouldn't be exactly the same either.

Don't Panic—But Don't Ignore a Meaningful Change

A headache can be frightening, particularly when it is severe or unfamiliar. Searching symptoms online can make that anxiety even worse.

Most headaches are not caused by brain tumors, aneurysms or other conditions requiring neurosurgery. At the same time, knowing the warning signs is important.

If something about your headache is sudden, significantly different from your normal pattern, progressively worsening, or accompanied by neurological symptoms, seek medical evaluation.

Sometimes the most important outcome of that evaluation is simply reassurance. And when there is an underlying problem, identifying it gives us the opportunity to determine the most appropriate—and whenever possible, least invasive—way to address it.

Ravi H. Gandhi, M.D.Board-Certified NeurosurgeonFellowship-Trained in Cerebrovascular, Endovascular and Skull Base Neurosurgery

Medical Disclaimer: This article is provided for general educational and informational purposes only and is not intended to provide medical advice, diagnosis or treatment. Every patient and medical situation is different. Talk with your physician or other qualified healthcare provider about your individual symptoms and medical needs. If you are experiencing a medical emergency, call 911 or seek emergency medical care.