Young businesswoman with her head down on her office desk

Why your head hurts

Headache is one of the world’s most common health issues. Some 40 million Americans suffer from headaches, but that suffering is often misunderstood.  

Because pain is subjective, it’s hard for people who do not suffer headaches to appreciate the severity and the relentlessness. Plus, there’s a stigma attached to headache complaints. But headaches, and migraine headaches in particular, reduce quality of life, prevent full participation in work and activities, and even alter mood. Migraine is the most common disabling brain disorder.  

Headache specialists, such as internist Chantel Strachan, MD, are part of initiatives to educate more primary care physicians on headache and migraine. Strachan, who completed a fellowship in headache and facial pain, shared the basics with us.

What is a headache?  

Headaches happen when an unknown mechanism activates nerves in your body that send pain signals to the brain. This mechanism is activated by a variety of factors including stress, sleep deprivation, hunger, alcohol, computer screens, and teeth grinding, to name a few. 

A headache can be its own medical condition, and a headache can be a symptom of something else, including: 

  • Dehydration 
  • Medication side effect 
  • Medication overuse 
  • High blood pressure 
  • Sinus congestion 
  • Tumor  
  • Migraine 

Migraine is not the name of a type of headache. It’s a neurological disease that causes recurrent, debilitating headaches and other symptoms, such as nausea and sensitivity to light and/or sound, and each episode can last for weeks.  

How do I get rid of a headache? 

The most common type of head pain is a tension headache, which can be caused by physical and emotional stress, anxiety, or head injury. Tension headaches are usually treatable with acetaminophen (Tylenol) or ibuprofen (Advil).  

Some people need stronger medication, such as Excedrin migraine or other over-the-counter drugs with added caffeine, and sometimes prescription medication. 

Many people get relief from massage, acupuncture, and eating fresh, healthier foods. 

When should I see a doctor about headaches? 

If a headache does not go away within three days with any of these methods, contact your doctor. It may be a sign something more than a headache is going on. 

When should I go to the ER with a headache?  

If a headache is not responsive to over-the-counter medications—and is so severe that it’s an obstacle to any activity for a few hours—contact a doctor or go to the ER.  

If you or someone around you has a headache, watch for other symptoms, such as vision changes, weakness on one side of face or body, confusion, or changes in walking.  

If you notice any of these or other unusual or severe symptoms, contact a doctor immediately or go to an emergency room. 

What is migraine? 

Migraine is a neurological disease that causes a variety of symptoms, including headache. Migraine attacks happen when nerves in and near blood vessels are activated and send pain signals to your brain. 

The cardinal symptoms of a migraine are intense throbbing headache, typically on one side of your head, and the following:

  • sensitivity to light and/or sound 
  • blurry vision  
  • dizziness 
  • stomach upset, including nausea, vomiting, and loss of appetite 

Migraine phases 

Migraine has four phases. Not every person who suffers migraine experiences all four phases, and each attack can be different. Some symptoms can occur across more than one phase.  

  1. Pre-monitory: Can be experienced up to seven days before head pain starts. Signs include cravings, irritability, and tiredness. 
  2. Aura: About 17% of migraines include aura. The most common is visual, usually accompanied by weakness. Aura can last up to 60 minutes before head pain starts. 
  3. Head pain: What most people associate with migraine is the third phase, which can include nausea, vomiting, and the need to lie down. Pain lasts for at least four hours. The longer you wait to treat migraine the longer it will last. 
  4. Postdrome: After the headache, symptoms can still be intense, including feelings of confusion or brain fog, similar to a hangover.  

The whole migraine attack process can take weeks. 

In the past decade, after more was discovered about the biochemistry of migraines, new medications have become available for treatment and prevention of migraine. Many medications are directed at reducing the amount of CGRP—calcitonin gene-related peptide—which has a role in pain in the brain and nervous system. Discuss with your doctor if these are good treatment options. 

Should I go to a headache specialist or a neurologist if I suffer headaches?  

If your headache doesn’t warrant a trip straight to the emergency room (again, watch for unusual symptoms, such as changes in mobility), go to a primary care physician first, ideally someone who specializes in headache. A primary care physician can determine if something else is going on, such as high blood pressure, anemia, or depression. A primary care physician is trained to look at the big picture, not just focus on the headache.  

Neurologists are great, and you may need one, but don't self-diagnose. Let another doctor refer you to the right specialist.   

Headaches can be serious. If you are not getting the help you need, do not give up. More and more doctors are receiving training to provide support.   


Chantel Strachan, MD, is an internist and a headache specialist at Columbia Primary Care. She is an expert in administering Botox injections for chronic migraine and administration of nerve block and trigger point injections. She is assistant professor of medicine at Columbia University Vagelos College of Physicians and Surgeons.

Headache & Facial Pain Specialists | Columbia Neurology