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Category: Neurological Disorders

Headache on Top of Head, Causes, Symptoms

Headache on Top of Head, causes, symptoms and treatment
There are many causes of “headache on top of head”. In this post we will describe the most common causes and their manifestations.

Tension-type headaches
These types of headaches are mostly located on top of the head and also on the sides. They are more prevalent in people who are suffering from stress or depression. The muscles around the skull become tight and lead to dull ache involving the whole head, patient describes this feeling as something pressing on the bed or there is a tight vice type band around the head squeezing the head. Mostly, it is a non pulsatile headache and is not accompanied by photophobia or intolerance to loud noise. Patients can still continue to function at their jobs because the intensity of the pain is not as severe as migraine headaches. These headaches usually start right after the patient wakes up in the morning and persist throughout the day, they get worse on exposure to loud noise and stress. These headaches tend to get better by relaxation or after going to sleep and patients hardly notice the pain during the night if they wake up to visit the bathroom.The pain starts in the morning sometime after getting up.

Most of the patients end up using over-the-counter medications like Tylenol or ibuprofen on a daily basis and if these drugs are used in excessive amounts daily, patients start developing rebound headaches which continue to occur on a daily basis.

Treatment of such headaches is usually by reduction of every day stress, discontinuation of excessive use of over-the-counter pain killers and treatment with one of the tricyclic antidepressants like doxepin or amitriptyline in small dosage. Some people get benefit from use of muscle relaxants.

Migraine headaches
These headaches can also occur on top of head however, usually they are unilateral or diffuse in location. These headaches are pulsatile headaches where patient feels heart pounding in the head and  are accompanied by nausea/vomiting, intolerance to loud noise and bright lights,  making it necessary for the patient to rest in a quiet and dark place. Some of these headaches are preceded by visual auras during which patient experiences zigzag flashing lines moving back and forth across the vision lasting for 10-20 minutes after which the headache starts. Sometimes migraine auras can be sensory or motor in nature when a person develops slow onset of sensory disturbances or weakness affecting one side of the body which comes on gradually, after which the migraine headache starts.

If migraine phenomenon is the cause of pain on top of the head and these attacks have been occurring frequently, they can be treated with preventive or abortive therapies. If these migraine headaches occur more than 3 or 4 times a month then use of preventive medication is helpful. Following drugs are commonly used to prevent the headache from coming back, and if they do, at least they are not as frequent or severe in degree.
Preventive Therapy

There are a number of other medications which can be used for preventive therapy.

If one chooses to use one of the above medications, then it is started at a very small dose on daily basis and the dosage is slowly increased over a period of many weeks until the patient is on therapeutic dosage. If a medication does not work or leads to too many side effects, it can be substituted with another medication, on occasion, in refractory patients combination of 2 medications is used and found to be effective.

Abortive therapy;
following medications are usually used.

These medications are used right at the onset of the warning signs of migraine headache, they lessen the duration and intensity of the migraine headache. They are usually not as effective if used when migraine headache is already full blown.

Cervicogenic headaches
Such types of headaches start in the neck muscles and spread to involve the top of the head and are accompanied by pain and stiffness of the neck muscles, some of the patients have history of whiplash injury but it can also occur in patients who have significant degenerative arthritis involving the cervical spine or have cervical spine C2/C3 facet joint disease.

If it is secondary to facet joint arthritic changes, then facet joint injection can be very helpful in relieving the symptoms however, facet joint dysfunction usually leads to unilateral headaches although occasionally the pain can be bilateral on top of the head. If the headaches are secondary to stiffness and tension of the cervical muscles , they can be treated with use of muscle relaxants, antidepressants medications as described above or with massage therapy.

Exertional headaches
Such types of headaches occur acutely during exertion like exercising, swimming, lifting weights, heavy exertion, intercourse and the onset can be acute and rapid where patient feels sudden onset of severe degree of headache on top of head, such headaches are also known as “thunderclap headaches” due to the acuteness of the onset.

Treatment of exertional  headaches is with use of NSAIDs, particularly indomethacin.

Coital Headache
These headaches belong to the above group and they can be of 2 types, one is a slow development of the headache during sexual excitement and sexual activity which gradually builds up until it feels like pressure type pain involving the top of the head and can become intense and it subsides after the sexual activity is over over half to 2 hours. These headache appear to be “tension type”

Thunderclap Headache
Another type of headache which occurs more commonly during sexual acuity is thunderclap headache at the time of orgasm where, patient develops very intense severe degree of explosive pain over the head, specially the top of head. It subsides after 10-30 minutes gradually. Some patients become fearful of sexual activity because it leads to such severe headaches at orgasm. These headaches are usually treated with use of propranolol or indomethacin which is taken half an hour before the sexual activity.

If the headache is of thunderclap type for the first time, it is important to rule out possibility of ruptured aneurysm by clinical examination, CT scan of the brain and possibly lumbar puncture for examination of the cerebrospinal fluid.

Ice pick headaches
These headaches have been described in this blog under another post ” Ice pick Headaches“. They last  for a few seconds only each time and are very sharp and might occur multiple times throughout the day or they might be occurring once in a while. These types of headaches are more common in people who suffer from migraine and tension-type headaches. If they occur once in a while, no treatment is necessary, but if they occur too often, use of indomethacin has been found to be very effective although this medication can lead to serious side effects like gastric ulcers, kidney problems or hematological disturbances so it’s use needs to be closely monitored and it should not be used on long-term basis.

Headaches due to low or high intracranial pressure
Under this category following are included
Post lumbar puncture headache
Idiopathic intracranial hypotension
Benign intracranial hypertension

Post lumbar puncture headache
Sometimes a person can develop headache after having a spinal tap which lasts for a few days afterwards. It is due to leakage of spinal fluid through a tear in the dura which persists after the spinal tap and cerebrospinal fluid continues to leak through this tear and intracranial pressure becomes low. These headaches occur when the patient assumes upright sitting position and subside when they lay down flat. They describe intense pain over the top of the head on assuming the upright posture and feel like there brain is being pushed down. Such headaches are quickly relieved after a blood patch over the dura which leads to closing the leakage through the dural membrane tear.

Idiopathic intracranial hypotension
These headaches are exactly like post lumbar puncture headaches however they come on spontaneously and are thought to be due to development of tear in the dura spontaneously during heavy exertion leading to continuous leakage of cerebrospinal fluid and the treatment is the same with blood patch, which closes the dural tear.

Idiopathic intracranial hypertension “pseudotumor cerebri”
In this condition, there is increase in the intracranial pressure due to increased production or decreased absorption of the spinal fluid. These headaches usually occur in younger obese females, particularly the ones who are on birth control pills, corticosteroids, high dosage of vitamin A. and D. or on expired antibiotics or tetracycline. Most of the time, they occur without any cause. Patient feel diffuse top of the head pain which is persistent, and it is made worse with exertion, bending, coughing. Patient’s also experience blurring or diminution of the vision on bending forward or coughing.

If intracranial pressure is highly elevated, it can lead to compression of the optic nerves and thus blindness in the eyes and it becomes an emergency .
Diagnoses is made by doing a spinal tap and measuring the opening pressure which is usually highly elevated. Treatment is with use of Diamox and sometimes drainage of the spinal fluid and removing  about 30 cc of cerebrospinal fluid daily  for several days. If patient is obese, reduction of body weight helps to  reduce the intracranial pressure. If there is danger of blindness, optic nerve fenestration procedure is done to release of pressure over the optic nerves, sometimes, ventriculoperitoneal  or lumboperitoneal shunt placement becomes necessary.

Ice Cream Headache
It is more common in adolescents and younger people, when palate is exposed to cold stimuli like during eating ice cream, patient feels severe degree of pain on top of the head which lasts only for very short time,

Cough headaches
Some patients experience headaches on top of the head during coughing, it is mostly benign condition however it is very important to rule out the possibility of brain tumor or Arnold-chiari malformation.

Other uncommon causes of “headaches on top of the head” can be following.

Cerebral tumor
These headaches can come on gradually and they can be on one side or diffuse and can be of pressure or throbbing type and might be accompanied by other neurologic signs indicating  involvement of the brain regions by the tumor, this possibility can be ruled out by doing MRI scan of the brain.

Intracranial infections of chronic nature
Such infections can be fungal or parasitic infections which are chronic in nature and lead to slow onset of headaches which can persist on daily basis accompanied by other neurologic symptoms like memory disturbances, coordination problems, speech disturbances, weakness or numbness affecting either side of the body and other neurologic symptoms.
Diagnosis is made by doing MRI scan of the brain and cerebrospinal fluid examination.

Carcinomatous meningitis
can also lead to headaches on the top of the head. Pt has h/o malignancy which has spread to the brain coverings ( leptomeninges)

Eagle’s syndrome
It is due to elongated styloid process of the skull which can compress against the carotid artery and leading to intermittent pain radiating to the top of the head or the side of the head. Diagnosis can be made by taking x-rays of the skull and findings of elongated styloid process which can be surgically

Occipital condyle syndrome
It is due to spread of the cancer to the base of the skull and destroying the occipital condyle and may be hypoglossal nerve next to it, and  leading to  pain on top of the head and findings of tongue weakness on one side although sometimes no weakness of the tongue is present because of sparing of the hypoglossal nerve supplying the ipsilateral side of the tongue.

Metastasis to the Skull
Some cancers spread to the bones including the skull and this can lead to headaches which can be located on the top of the head. Again the diagnoses is made by neuroimaging and spinal fluid examination

Chronic Sub-Dural Hematoma
Can lead to diffuse headaches on top of head


Hypnic Headaches
these headaches tend to occur in older people and wake a person up during sleep, sometime the same time of the night daily. Such headaches are of pressure and throbbing type and affect the whole head, they are not accompanied by nausea, vomiting or photophobia, they can last from 45 minutes to a couple of hours. If they occur frequently, they can be treated with Lithium 200-300 mg at night time


Airplane Headaches during ascending or descending
They occur in people who suffer from sinusitis and blockage of the sinuses leading to alteration in the barometric pressure in the sinuses during ascent or descent of the plane, Pain can be intense around the eyes or top of the head, they are helped with treatment of the sinusitis and use of antihistamine drug an hour before boarding the plane and avoiding use of alcohol during the flight because it dilates the blood vessels and causes congestion of the inflamed sinuses.

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