Category: Headache types and diagnosis

Most headaches do not need a scan. Imaging is warranted after head trauma, for a sudden or thunderclap onset, a new headache at 50 or over, a neurological deficit, or a headache brought on by coughing, exertion or sex. Outside an emergency, MRI is the test.

If nobody has scanned your head, that is usually the correct decision rather than a corner being cut. It is also the single most common thing people arrive here suspicious about. So it is worth explaining properly.

What the guidelines actually say

The American Headache Society’s Choosing Wisely list opens with it: do not perform neuroimaging in patients with stable headaches that meet criteria for migraine.¹ The American College of Radiology reaches the same conclusion from the imaging side — most patients with uncomplicated, non-traumatic, primary headache do not require imaging.²

This is not a cost-cutting position dressed up as evidence. Take a headache that fits a primary pattern, with a normal neurological examination. There, a scan is overwhelmingly likely to be normal. And a normal scan does not change the treatment. What changes the treatment is the diagnosis. The diagnosis is made from the history and the examination.

When does a headache need a scan?

The features that shift the balance are specific and worth knowing. The ACR lists headaches that are:^2,3

• Associated with head trauma.
• New, worse, or abrupt in onset — including thunderclap headache, which reaches maximum intensity within seconds.
• Persistent and positional — clearly worse lying down, or clearly worse standing up.
• Radiating to the neck.
• Accompanied by a neurological deficit on examination, or by optic disc swelling.
• New in someone aged 50 or over, particularly temporal headache.
• Occurring in specific contexts — pregnancy, cancer, an immunocompromised state, or a systemic illness including a clotting disorder.^2,3

The three most people do not expect

Headaches brought on by coughing, by exertion, or by sexual activity usually require MRI of the brain with and without contrast. This is done to exclude underlying pathology before a primary headache syndrome is diagnosed.²

That is worth reading twice. That is because these are exactly the headaches people are least likely to mention. A headache that only happens when you cough, or when you lift, or during sex, feels embarrassing or trivial rather than alarming. It is the reverse. Tell us about it.

MRI or CT

Where imaging is indicated and it is not an emergency, MRI is the right test. The Choosing Wisely list is explicit: do not perform CT for headache when MRI is available, except in emergency settings.¹ CT is fast, and it is very good at finding acute bleeding. That is why it is the emergency test. It involves ionizing radiation. And it is far less sensitive for most of what else might be found.

What does a normal brain scan rule out?

A normal scan rules out a structural lesion. It does not rule out migraine, cluster headache, occipital neuralgia, cervicogenic headache or medication-overuse headache — none of which are visible on imaging at all. Every one of those is diagnosed clinically.

So a normal MRI is not a dead end. It is not a statement that nothing is wrong. It is the expected result. It moves the question to where it belonged: which primary headache disorder is this, and what drives it. See migraine or tension-type headache and occipital neuralgia or migraine.

The case against scanning everyone

Yield (how often a scan finds something useful) is the first argument. In children with recurrent headache and a normal neurological examination, neuroimaging produces actionable findings in roughly 0 to 4.1% of cases.⁴ That is a pediatric figure and should not be read as an adult number. But the direction holds across the literature, and it is the basis for the guidelines above.

The second is what a scan finds that has nothing to do with your headache. Incidental findings are common. They generate follow-up imaging and specialist referrals. And they cause real anxiety over something that was never causing symptoms. Picture a test that is very unlikely to explain your problem and reasonably likely to raise an unrelated one. That test is not a neutral act.

The third is time. Waiting on a scan that was never going to change the plan is time not spent treating the headache.

What we do instead

We examine you, which includes the parts frequently skipped — the neck, the jaw, the occipital nerves and the exit points of the superficial trigeminal branches. See is my headache coming from my neck and TMJ as a missed cause of headache.

Where the source is genuinely uncertain, an image-guided diagnostic block answers a question a scan cannot. If anesthetizing (numbing) a specific nerve abolishes the pain, that nerve is carrying it. If it does not, the pain arises elsewhere. That is a functional test rather than a structural one. And headache is a functional problem — see do nerve blocks for headache work and why image guidance matters.

And if anything in your history or examination puts you in the list above, we say so and arrange the imaging. The point is not that scans are unnecessary. It is that they should be aimed.

Common questions

Should I ask for an MRI?

Ask what in your history or examination would make one useful. If the answer is nothing, a scan is very unlikely to change your treatment.^1,2 If you have any of the features listed above, say so explicitly — contact us with the detail.

My headaches are severe. Does severity justify a scan?

Severity on its own is not one of the features that predicts a finding. Abrupt onset, a change in pattern, a positional element, or an abnormal examination are. Severe pain from a primary headache disorder is still a primary headache disorder — see headache red flags for what does warrant urgent attention.

I had a normal CT in the emergency department. Is that enough?

For excluding acute bleeding, usually yes, and that is what it was for. It is much less sensitive for other findings. That is why MRI is preferred outside emergencies.¹ Whether anything further is needed depends on your pattern.

Only my cough brings it on. Is that worth mentioning?

Yes, specifically. Cough, exertional and sexual-activity headaches usually warrant MRI with and without contrast before being called primary.² These are the ones people most often leave out.

Will you order the scan, or does my primary care doctor?

Either. If imaging is indicated we will arrange it or coordinate with whoever is best placed to. Note that authorization timelines and same-day treatment do not run on the same clock — see the coverage note on any of our treatment pages.

Can an MRI detect migraine or other headaches?

No. A normal scan excludes a structural lesion. But migraine, cluster headache, occipital neuralgia, cervicogenic headache and medication-overuse headache are not visible on imaging at all. Each is diagnosed clinically, from the history and the examination. So a normal MRI is the expected result, not a statement that nothing is wrong.

Is it worth getting an MRI for headaches?

Only when something in your history or examination points to it. Take a headache that fits a primary pattern with a normal neurological examination. A scan is overwhelmingly likely to be normal and does not change the treatment. It can also turn up incidental findings that bring more imaging and real anxiety. It is worth it after head trauma, with a thunderclap onset, a new headache at 50 or over, or a neurological deficit.

Which is better for headaches, a CT scan or an MRI?

Outside an emergency, MRI. The Choosing Wisely list says not to perform CT for headache when MRI is available, except in emergency settings. CT is fast and very good at finding acute bleeding. That is why it is the emergency test. But it involves ionizing radiation and is far less sensitive for most of what else might be found.

Sources

1. Loder E, Weizenbaum E, Frishberg B, Silberstein S. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659. doi:10.1111/head.12233
2. Douglas AC, Wippold FJ, Broderick DF, et al. ACR Appropriateness Criteria Headache. J Am Coll Radiol. 2014;11(7):657-667. doi:10.1016/j.jacr.2014.03.024
3. Whitehead MT, Cardenas AM, Corey AS, et al. ACR Appropriateness Criteria® Headache. J Am Coll Radiol. 2019;16(11S):S364-S377. doi:10.1016/j.jacr.2019.05.030
4. Irwin SL, Gelfand AA. Occipital headaches and neuroimaging in children. Curr Pain Headache Rep. 2018;22(9):59. doi:10.1007/s11916-018-0712-6

Supraorbital neuralgia is pain from the supraorbital nerve. This trigeminal branch exits the brow ridge just under the skin. A direct hit to the brow presses it against bone. It causes forehead pain above one eye that never switches sides. It is confirmed when a nerve block relieves it.

A blow to the eyebrow can leave a headache behind long after the bruise has gone. Is your forehead pain always on the same side, above one eye? Can you find a tender spot on the brow ridge? Then this is a specific, treatable diagnosis, not an unexplained headache.

Why does an eyebrow injury damage the supraorbital nerve?

The supraorbital nerve is a branch of the first division of the trigeminal nerve. It leaves the skull through the supraorbital notch or foramen. That is a gap you can feel on the upper rim of the eye socket, about a third of the way out from the midline. From there the nerve fans out to supply the forehead and the front of the scalp.

At that exit point it is close to the surface and lies against bone. Only skin, muscle and eyebrow cover it. A direct blow to the brow presses the nerve against the orbital rim (the bony edge of the eye socket). That anatomy is why this happens after an elbow in basketball, a fall onto the brow, a windshield or airbag impact, an assault, or a laceration (cut) repaired over the eyebrow. Surgery in the area, including brow lifts, can do the same thing.

What does supraorbital neuralgia feel like?

Supraorbital neuralgia has a described diagnostic triad. It is made up of forehead pain in the area the nerve supplies, without switching sides; tenderness over the supraorbital notch or along the path of the nerve; and complete but temporary relief of the pain when the nerve is blocked with local anesthetic.¹

One series followed 18 patients over seven years. The pain was typically dull, with short sharp or burning flares. It sat in the forehead and around the eye. Five of the 18 had a history of trauma to the forehead on the same side. About two-thirds were women. Average age at onset was 51.6 years. By the time they were studied, they had been in pain for an average of 5.9 years.²

Two features point specifically toward a nerve injury rather than a primary headache:

• It never changes sides. Migraine can favor one side but generally shifts at least now and then. A pain rigidly locked to one side of the forehead for years is doing something different.
• The skin over it behaves oddly. Numbness, pins and needles, or a forehead that hurts to light touch or to the brush of a hairbrush. In a population study, around half the cases found had measurable loss of feeling on the affected side.³ These sensory features, and sharp jabbing pains, are reported more often in the post-traumatic form than in cases with no injury behind them.¹

How common is supraorbital neuralgia?

The literature describes supraorbital neuralgia as rare. In headache clinics it is diagnosed rarely. A population study points the other way. It looked at 1,838 residents aged 18 to 65 in Vågå, Norway, which was 88.6% of those eligible. Ten met the case definition, a prevalence of about 0.5%.³

The case definition used in that study is worth reading closely, because trauma was built into it. It required unilateral forehead or eye pain, firmly one-sided. It required more tenderness over the nerve’s exit point. And it required preceding trauma to the forehead or supraorbital rim on the same side.³

Half a percent of a general population is not rare. The likeliest reading of the gap is that the diagnosis is under-recognized, not truly uncommon. People with a decades-old brow injury and a one-sided forehead headache are being carried under a different label. Still, that is a single population, in one Norwegian valley. The figure should be treated as one good estimate rather than a settled number.

What can supraorbital neuralgia be mistaken for?

• Migraine. The overlap is real, and the two can coexist. Side-locking, a tender notch and changed feeling on the forehead are the features that should prompt a second look. See migraine treatment.
• Sinus headache. Frontal pain above the eye is routinely blamed on the frontal sinus. See is it a sinus headache or a migraine.
• Cluster headache. Also strictly one-sided and centered around the eye. But it has prominent tearing, a stuffy nose and a striking circadian (daily timing) pattern. Supraorbital neuralgia does not have these. See migraine or cluster headache.
• Post-concussive headache. A blow hard enough to injure the nerve may also have caused a concussion. Both can be present. One does not rule out the other.
• Thyroid eye disease. A review looked at 1,126 patients with thyroid eye disease. Of them, 8% reported a distinct pain suggestive of supraorbital neuralgia. All of them had complete relief from a supraorbital nerve block.⁴ This is worth knowing if there is eye bulging or a thyroid history.

How is supraorbital neuralgia diagnosed and treated?

There is no scan for this. The diagnosis is made from the pattern, the tender point, and the response to numbing the nerve. Complete relief while the anesthetic is working confirms that the pain is coming from that nerve.¹ A negative result tells you just as much. It says the pain is coming from somewhere else, and the diagnosis moves on.

That is only true if the injected medicine reached the nerve. This is the reason every injection here is placed under imaging rather than by feel. See ultrasound and fluoroscopic guidance and why image guidance matters. A failed landmark (by-feel) block tells you nothing at all.

Medication tends to disappoint here. In the 18-patient series, trials of various drugs gave only slight relief. These included migraine and anti-neuralgic drugs. By contrast, anesthetic block of the nerve gave absolute relief for as long as it lasted.² Relief often outlasts the anesthetic’s own action, sometimes by weeks. See do nerve blocks for headache work and trigeminal nerve block.

For the minority who do not respond durably to blocks, other options exist in the literature. One study used pulsed radiofrequency on the supraorbital nerve under ultrasound in 22 patients with refractory (hard-to-treat) disease. At least 50% pain reduction was reached in 77% at one and three months, 73% at six months, 64% at one year and 50% at two years. About a quarter had mild upper-eyelid bruising, and there were no serious complications.⁵ That is a small, single-arm study with no control group. So treat it as encouraging rather than established.

What to bring to the appointment

• When the injury happened, and what hit you. Decades ago still counts.
• Whether the pain has ever been on the other side. Be precise here. It carries more diagnostic weight than the severity.
• Whether the forehead skin on that side feels different: numb, tingling, or too sensitive.
• Anything already tried, including migraine treatments, and whether any of it helped.
• Any scar over the eyebrow, and any surgery in the area.

Frequently asked questions

My eyebrow injury was years ago. Can it still be the cause?

Yes. In one series the average time in pain before assessment was 5.9 years. Cases have been described far longer after the injury than that.² An old injury is a reason to examine the nerve, not to dismiss it. Contact us with the history and we can tell you whether it is worth assessing.

How do I know if it is this and not migraine?

The strongest clue is that the pain never moves to the other side. That is combined with a tender spot on the brow ridge and changed feeling on that side of the forehead.¹ The two can also coexist. See migraine or tension-type headache for how the primary headaches are told apart.

Does the diagnostic block hurt, and will I need sedation?

No sedation, and you drive yourself home. It is a superficial injection over the brow ridge and takes seconds. What to expect from a nerve block describes the same process at the back of the head.

What if the block does not help at all?

Then, as long as it was image-guided, that is a useful result, not a wasted visit. It means the pain is not coming from that nerve, and the diagnosis moves elsewhere. See why image guidance matters.

Will the numbness on my forehead come back?

Loss of feeling from the original injury may or may not recover. Treating the pain does not necessarily restore feeling. The anesthetic itself causes temporary numbness over the forehead that fades in hours. That is the expected effect of blocking that nerve. See trigeminal nerve block.

What are the first signs of supraorbital neuralgia?

Pain in the forehead above one eye that stays on the same side every time. It comes with a tender spot on the brow ridge where the nerve exits. The skin on that side often behaves oddly: numbness, pins and needles, or a forehead that hurts to light touch or the brush of a hairbrush. The pain is usually dull, with short sharp or burning flares.

What causes supraorbital neuralgia?

A direct blow to the brow that presses the nerve against the bone of the eye socket. There, it lies just under the skin. Typical causes are an elbow in basketball, a fall onto the brow, a windshield or airbag impact, an assault, or a cut repaired over the eyebrow. Surgery in the area, including a brow lift, can do the same.

Can supraorbital neuralgia go away?

Left alone, it tends to persist. In one series, people had been in pain for an average of 5.9 years before assessment. A nerve block relieves the pain completely while it works. The relief often lasts well beyond the anesthetic, sometimes by weeks. For the few who do not respond durably, pulsed radiofrequency to the nerve is another option.

Sources

1. Pareja JA, Caminero AB. Supraorbital neuralgia. Curr Pain Headache Rep. 2006;10(4):302-305. doi:10.1007/s11916-006-0036-9
2. Caminero AB, Pareja JA. Supraorbital neuralgia: a clinical study. Cephalalgia. 2001;21(3):216-223. doi:10.1046/j.1468-2982.2001.00190.x
3. Sjaastad O, Petersen HC, Bakketeig LS. Supraorbital neuralgia. Vågå study of headache epidemiology. Cephalalgia. 2005;25(4):296-304. doi:10.1111/j.1468-2982.2004.00856.x
4. Patrinely JR, Hamilton KL, Parke RB, Patrinely JR, Soparkar CNS. Supraorbital neuralgia associated with thyroid eye disease. Ophthalmic Plast Reconstr Surg. 2021;37(3):230-235. doi:10.1097/IOP.0000000000001762
5. Luo F, Lu J, Ji N. Treatment of refractory idiopathic supraorbital neuralgia using percutaneous pulsed radiofrequency. Pain Pract. 2018;18(7):871-878. doi:10.1111/papr.12687

TMJ problems cause headache more often than they are diagnosed. In headache patients the trouble is usually in the chewing muscles, not the joint. So it lands in the temples, reads as a tension headache, and slips past a normal jaw X-ray.

Does your headache sit in the temple? Does it come with jaw tightness, or get worse after a meal or a stressful night of clenching? Then the jaw is worth examining before anything else is added to your treatment. It is one of the most commonly missed contributors to headache. It is also one of the few that is easy to check in a few minutes.

What is a temporomandibular disorder (TMD)?

Temporomandibular disorder, or TMD, is not one condition. It covers problems of the temporomandibular joint itself, problems of the muscles that move the jaw, or both. In headache patients the muscle form dominates. In a study of 132 people with migraine, myofascial pain (muscle pain) was the most prevalent form of TMD in both the episodic and chronic groups.¹

That matters, because a muscle problem does not show up on a jaw X-ray. People are sent for imaging and told the joint looks normal. They reasonably conclude the jaw was a dead end. The joint was never the question.

Two different relationships, and the distinction changes the treatment

There are two ways a jaw problem and a headache can be connected, and they are not the same thing.

• The TMD is causing the headache. The International Classification of Headache Disorders recognizes this as a secondary headache, item 11.7, headache attributed to temporomandibular disorder.² Treat the jaw and the headache should follow.
• The TMD and a primary headache coexist. Migraine and tension-type headache are truly comorbid with TMD. Having one raises the likelihood of the other.² Here the jaw is a load on a system that already has a headache disorder. Both need addressing.

Efforts to find a distinctive fingerprint for the secondary type have largely failed. The most that can be said is that it tends to sit in one or both temples. It tends to look either migraine-like or tension-type-like.² So the label cannot be settled from the description of the pain alone. That is exactly why the jaw has to be examined rather than asked about.

How common is TMJ in people with frequent migraines?

The association is strongest in the group that has the most to gain. One single-center study looked at 90 people with chronic migraine and 42 with episodic migraine. TMD was present in 60% of the chronic group against 21.4% of the episodic group.¹ A separate study from the same group, in 63 chronic and 40 episodic migraine patients, found 47.5% against 28.5%.³

Both are modest, single-center samples. The exact percentages should not be read as precise. The direction is the consistent finding: the more frequent the headache, the more likely the jaw is involved. Frequent neck pain tracked the same way in the larger study. It was reported by 65.5% of the chronic group and 21.4% of the episodic group.¹

The relationship also runs the other way. A 2024 systematic review of cohort studies found that headache frequency, tension-type headache, migraine and mixed headache were themselves risk factors for developing TMD.⁴ Neither is simply causing the other. They feed each other.

The chronification question

The bigger possibility is that untreated TMD helps push migraine from episodic toward chronic. This has been argued for over fifteen years. The proposed link is cutaneous allodynia, meaning tenderness of the scalp and face between attacks.⁵ The evidence that TMD drives this shift remains limited. It would be overstating it to say the case is settled.

But the practical conclusion does not depend on settling it. Take someone whose headaches are becoming more frequent. In that person, a treatable source of continuous input into the trigeminal system is worth removing on its own merits. If it also slows the shift to chronic, that is a second reason. See chronic or episodic migraine for why the 15-day line matters so much.

Why is a TMJ headache so often missed?

• Temple pain reads as tension-type headache. The temporalis is a chewing muscle. Pain from it lands exactly where people expect a stress headache to be. See migraine or tension-type headache.
• The jaw is not examined in a standard headache visit. Pressing on the masseter and temporalis and measuring jaw opening takes about two minutes. It is often skipped.
• Patients do not report it. People do not think of jaw clicking and morning tightness as headache symptoms. So they do not mention them unless asked.
• A normal joint image closes the file. As above, the common form is muscular. Imaging of the joint does not rule it out.

How can you tell if your headache is coming from your jaw?

None of this is diagnostic on its own. But it is worth arriving with the answers:

• Does the pain start or worsen while chewing, especially something tough?
• Is your jaw tight or sore on waking? That points toward clenching or grinding overnight.
• Can you fit three of your own fingers, stacked vertically, between your upper and lower front teeth? Less than that suggests restricted opening.
• Press firmly into the muscle at your temple and into the thick muscle at the angle of the jaw. Is one side clearly more tender?
• Does the jaw click, catch, or deviate to one side as it opens?

How are TMJ headaches treated here?

The jaw and the chewing muscles are examined as part of a headache assessment, not as a separate referral. Sometimes a muscle pain source in the temporalis or masseter is contributing. That is treatable. It is treated alongside the headache disorder, not instead of it. Treating both conditions at the same time outperforms treating either one on its own.²

Where the joint itself, the bite, or nocturnal grinding is the primary driver, that is dentistry and orofacial pain territory, and we will say so and point you there rather than treat around it. Bruxism’s exact role in headache remains unclear even in the specialist literature.⁶

Is the neck also involved? In frequent headache it usually is. If so, see is my headache coming from my neck and cervicogenic headache treatment.

Frequently asked questions

Can a jaw problem really cause a headache, or is that a myth?

It is a formally recognized diagnosis. The International Classification of Headache Disorders lists headache attributed to temporomandibular disorder as item 11.7.² What is truly uncertain is how often a jaw problem is the only cause. It may instead be one contributor alongside a primary headache disorder. See migraine or tension-type headache.

My jaw X-ray was normal. Does that rule it out?

No, and this is the most common reason the diagnosis is missed. The form most often found in headache patients is myofascial. That is a muscle problem, not a joint problem. It does not appear on imaging of the joint.¹ The exam is done with hands, not a scanner.

Should I get a night guard?

Possibly, but that decision belongs with a dentist, and a guard addresses grinding rather than headache directly. Bruxism’s role in headache is still not well defined.⁶ It is worth doing in parallel with headache treatment rather than as a substitute for it — contact us and we will tell you which order makes sense in your case.

My headaches have become almost daily. Is the jaw worth checking at that point?

That is exactly the group where it is most worth checking. One study found TMD in 60% of chronic migraine patients against 21.4% of episodic.¹ Also check whether acute medication is keeping the pattern going. See medication-overuse headache.

Do you inject the jaw?

Where a muscle pain source is contributing, that is treatable. Any injection here is placed under imaging, not by landmark (by feel). See ultrasound and fluoroscopic guidance. Whether an injection is the right step depends on what the exam shows. That is why the assessment comes first.

What does a TMJ headache feel like?

It usually sits in one or both temples, where the temporalis chewing muscle lies. So it is easily taken for a stress or tension headache. It can also look migraine-like. Clues that point to the jaw are pain that starts or worsens while chewing, a tight or sore jaw on waking, and a jaw that clicks, catches or drifts to one side as it opens.

What is the 3 finger test for TMJ?

Stack three of your own fingers vertically and try to fit them between your upper and lower front teeth. If they will not fit, your jaw opening is restricted. That points toward a jaw problem. It is one piece of the picture, not a diagnosis on its own. So bring the result to your appointment along with any clicking, morning tightness or tender spots.

How are TMJ headaches diagnosed?

With hands, not a scanner. The doctor presses on the masseter and temporalis muscles and measures how far your jaw opens. This takes about two minutes. A jaw X-ray or joint scan is not enough. That is because the form most often found in headache patients is a muscle problem that does not show up on imaging of the joint.

Sources

1. Latysheva N, Platonova A, Filatova E. Temporomandibular disorder and cervicalgia: pathophysiology underlying the comorbidity with chronic migraine. Zh Nevrol Psikhiatr Im S S Korsakova. 2019;119(1):17-22. doi:10.17116/jnevro201911901117
2. Speciali JG, Dach F. Temporomandibular dysfunction and headache disorder. Headache. 2015;55(Suppl 1):72-83. doi:10.1111/head.12515
3. Zenkevich AS, Filatova EG, Latysheva NV. Migraine and temporomandibular joint dysfunction: mechanisms of comorbidity. Zh Nevrol Psikhiatr Im S S Korsakova. 2015;115(10):33-38. doi:10.17116/jnevro201511510133-38
4. Da-Cas CD, Valesan LF, Nascimento LP, et al. Risk factors for temporomandibular disorders: a systematic review of cohort studies. Oral Surg Oral Med Oral Pathol Oral Radiol. 2024;138(4):502-515. doi:10.1016/j.oooo.2024.06.007
5. Bevilaqua Grossi D, Lipton RB, Bigal ME. Temporomandibular disorders and migraine chronification. Curr Pain Headache Rep. 2009;13(4):314-318. doi:10.1007/s11916-009-0050-9
6. Romero-Reyes M, Bassiur JP. Temporomandibular disorders, bruxism and headaches. Neurol Clin. 2024;42(2):573-584. doi:10.1016/j.ncl.2023.12.010

Go to the emergency room for a headache that reaches its peak within seconds, a headache with fever and a stiff neck, or a headache with any neurological change such as weakness, trouble speaking or loss of vision.

Most headaches are not dangerous. A small number are, and they are recognizable. If any of the following applies, go to an emergency department or call 911 — do not wait for an appointment here.

Go now

• Thunderclap onset. A headache that reaches maximum intensity within seconds to a minute. The speed of onset is the warning sign, no matter how severe it ends up being.
• Headache with fever and a stiff neck, or with a new rash.
• Any neurological change — weakness, numbness, trouble speaking, loss of vision, double vision, unsteadiness, confusion, or a seizure.
• Headache after a head injury, particularly with vomiting, drowsiness or worsening.
• A new headache in someone who is pregnant or recently gave birth.
• A new or changed headache over the age of 50.
• A new headache in someone immunosuppressed or with a history of cancer.
• Headache with a red, painful eye and blurred vision.
• Headache that is consistently worse lying down, on waking, or with coughing and straining.

Why thunderclap is first on the list

Because the speed of onset is what sets it apart, and people routinely describe it by how severe it was instead. The question that matters is not “how bad was it” but “how long did it take to get that bad”. Seconds is the answer that requires emergency imaging.

If you have had a headache like that — even if it settled, even if it was weeks ago and you feel fine now — it should be assessed.

What we are, and what we are not

Headache Express is an outpatient clinic. We treat migraine, cluster and other recurring headache disorders, usually the same day. We do not have emergency imaging. We are not open overnight. We are not a substitute for an emergency department.

This line is the point of the clinic, not a limit on it. An emergency department is the right place for a headache that might be a bleed, an infection or a stroke. It is a poor place for a headache you already know the name of. You wait among sicker patients and often leave with a shot and a referral rather than a plan.

If you arrive here with features from the list above, we will tell you plainly and send you to an emergency department. That is the correct outcome, not a wasted visit.

What is not a red flag

Reassurance is worth as much as warning. So: severe pain by itself is not a red flag. Cluster headache is among the most severe pain in medicine and is not dangerous. Nausea and vomiting during a migraine are expected. Visual aura that builds over five to twenty minutes and clears within an hour is a recognized migraine feature.

What matters is change — a headache that is new, different from your usual pattern, or accompanied by something neurological that does not resolve.

If none of this applies

Then you are in the right place. See migraine treatment, cluster headache treatment, or the full list of treatments. Please contact us before coming in.

Common questions

My headache is the worst I’ve ever had, but it built over an hour. Is that thunderclap?

No. Thunderclap refers to onset within seconds. A severe headache that built over an hour is not thunderclap, though a new or unusually severe headache still deserves assessment. See contact us.

I had a sudden severe headache last month and I’m fine now. Do I still need to be checked?

Yes. A thunderclap headache that has settled still needs assessment. That is because some causes show up with a warning event before a larger one. That is an emergency department or urgent medical review, not an outpatient headache appointment. Once it has been ruled out, contact us about the ongoing headache pattern.

Is aura a warning sign?

Typical visual aura builds over 5 to 20 minutes and resolves within an hour. Sudden-onset visual loss, aura that does not resolve, or aura appearing for the first time over 50 are different and need assessment. See migraine treatment.

Should I go to the ER for a severe cluster attack?

Cluster pain is extreme but not dangerous. Emergency departments are often poorly set up to treat it. The better answer is a plan — including home high-flow oxygen — so you are not dependent on an ER at 3am.

Separately from the emergency question, it is worth knowing which headaches warrant a scan at all and which do not — see when a headache actually needs a scan.

Sources

1. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 2018. PMID 30587518. pubmed.ncbi.nlm.nih.gov
2. Sjulstad AS, Brekke OL, Odeh F, et al. Incidence and outcome of sudden severe headache in the emergency department. Headache, 2025. PMID 40859708. pubmed.ncbi.nlm.nih.gov

Chronic migraine is a defined diagnosis, not a way of saying you often feel unwell. It means headache on 15 or more days a month for more than three months, with at least eight of those days having migraine features.¹

The line matters because treatment options change on either side of it. It also matters because crossing it is usually a process you can interrupt.

The criteria, precisely

• Headache — of any type — on 15 or more days per month
• Sustained for more than three months
• On at least eight of those days, the headache has migraine features or responds to migraine-specific treatment
• In a person who has had at least five prior migraine attacks

Note that the 15 days counts all headache days, not just migraines. People routinely undercount by leaving out the “small” ones. That undercount is why many are told they do not qualify for treatments they in fact qualify for.

How episodic becomes chronic

Chronification (the shift from episodic to chronic) is not random. The known contributors are worth knowing, because most can be changed:

• Medication overuse — the largest single one. See medication-overuse headache.
• Untreated or undertreated attacks, which appear to make the system more sensitive over time
• Untreated mood and anxiety disorders, which independently predict progression
• Poor or irregular sleep, including undiagnosed obstructive sleep apnea
• Obesity and metabolic factors

That list is also the intervention list. See headache prevention.

What changes at the threshold

Botox is indicated for chronic migraine and not for episodic — the trials in people below 15 days did not show benefit. That is the clearest example. It is why counting honestly matters more than it seems.

Acute treatment also changes. Below the threshold, the priority is treating attacks well. Above it, treating every attack hard is part of what keeps the pattern going. So the plan has to shift toward prevention and toward unwinding rebound.

Chronic is not permanent

The most useful thing to know is that people move back across the line. Going back from chronic to episodic is common, especially when medication overuse is addressed. Many people arrive counting 20-plus headache days a month and, some months later, are counting far fewer. The largest single lever was usually the medicine cabinet rather than a new drug.

The word “chronic” describes your current pattern. It is not a prognosis.

Common questions

Do I count days when the headache was mild?

Yes. The 15-day rule counts headache days of any type and any severity, not just severe migraine attacks. Undercounting mild days is the most common reason people are told they do not qualify. See Botox for chronic migraine.

What if I’m at 12 or 13 days?

Then you have high-frequency episodic migraine. That is the group most at risk of crossing over — and the group where prevention pays off most. See headache prevention.

Can chronic migraine go back to episodic?

Yes, and it commonly does, especially once medication overuse is addressed. See medication-overuse headache.

How do I actually keep track?

A paper calendar with a mark for any headache day and a note of every dose of anything taken. Keeping it simple matters more than detail — a system you abandon in a week is worse than a tick per day. Bring it in; see contact.

Could my daily headaches be rebound headaches?

If you treat headache on 10 or more days a month (15 for plain ibuprofen, aspirin or acetaminophen), there is a real chance. The tell is a headache that is already there when you wake, eases only partly with your usual tablet, and gets worse within hours when you skip a dose. Rebound days count toward the 15-day line, so part of a chronic count can be manufactured by the treatment itself. See how medication-overuse headache is unwound.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 1.3 Chronic migraine. ichd-3.org

Cluster headache is one of the most severe pains in clinical medicine and one of the most delayed diagnoses. A systematic review and meta-analysis of eleven studies, published in 2025, estimated the average delay from onset to diagnosis at 10.4 years.¹

Single studies vary widely. Reported figures include 6.2 years, 5.7 years, a median of 3 years, and 12.7 years in a population-based sample.¹ This reflects real differences in populations and eras, not disagreement about the problem. The direction is consistent: years, not months.

Why it takes so long

It looks like sinus disease

The cranial autonomic features — a blocked or running nostril, a watering red eye, a drooping lid, all on the painful side — look like infection or allergy. People get repeated rounds of antibiotics across one bout after another. See is it a sinus headache or a migraine.

It looks like dental disease

Pain centered behind or around the eye that spreads into the upper jaw leads to dental testing, and sometimes to treatment. Pain that lasts after that work is its own problem — see persistent pain after dental treatment.

It gets called migraine

One-sided severe headache is assumed to be migraine. The assumption survives because nobody asks the two questions that would break it: how long does an attack last, and what do you do during one? See migraine or cluster headache.

The remissions are misleading

Episodic cluster comes in bouts with remission between them. A bout often ends while you are waiting for an appointment. Then the problem appears to have resolved, and the investigation stops.

The three features that identify it

A validated three-item screen developed at Houston Methodist — the Erwin Test for Cluster Headache — covers pain intensity, attack duration and autonomic features. Its validation study included 224 people with headache disorders, of whom 64 had cluster headache. The three items together had a sensitivity of 84% (95% CI 73–92) and a specificity of 89% (95% CI 84–94).²

Translated into what to tell a clinician:

• This is the worst pain I have ever had. Cluster is characteristically extreme, not merely bad.
• Each attack is over within about three hours. ICHD-3 puts untreated attacks at 15 to 180 minutes.³
• My eye waters and my nostril blocks, on the same side as the pain.

Then add the timing. Attacks arrive at the same hour, often waking you from sleep, from one every other day up to eight a day during a bout.³ Once someone is looking for it, the picture is hard to mistake.

What the delay costs

Years of the wrong treatment, obviously. But also years of not being believed, which is its own injury. Cluster headache is sometimes called suicide headache. It earned that name from the elevated rate of suicidal thinking among people living with it untreated. It is not a figure of speech.

Shortening it

The fastest route through is a clinician who has seen it. Dr. Gurpreet Singh Padda, MD, MBA, MHP has lived with chronic cluster headache since the age of 17. So the pattern is recognized here rather than argued about. Treatment starts with high-flow normobaric oxygen. It is first-line and works within minutes when given correctly.

See cluster headache treatment for the full picture.

If you are having thoughts of harming yourself, call or text 988 for the Suicide and Crisis Lifeline, 24 hours a day. Cluster headache is treatable and the pain is not a permanent condition of your life.

Common questions

What should I bring to speed this up?

A month of attack times to the hour, how long each lasted, which side, and what happened to your eye and nose. That single sheet does more than any scan. See contact.

Does a normal MRI mean I don’t have cluster headache?

No. Cluster is diagnosed from the attack pattern. Imaging is used to rule out other causes, and a normal result is expected. See cluster headache treatment.

My bout ended before my appointment. Should I still come?

Yes. Remission is part of episodic cluster, not evidence against it. The time between bouts is the best time to arrange preventive planning and a home oxygen setup. See oxygen therapy.

Is cluster headache hereditary?

Cluster headache runs in families in a minority of cases, but most people with it have no affected relative. A negative family history is not a reason to rule it out. See cluster headache treatment.

Sources

1. Peng K-P, et al. Cluster headache diagnostic delay and its predictors: a systematic review with a meta-analysis. The Journal of Headache and Pain, 2025. link.springer.com
2. Parakramaweera R, Evans RW, Schor LI, et al. A brief diagnostic screen for cluster headache: creation and initial validation of the Erwin Test for Cluster Headache. Cephalalgia, 2021. PMID 34148408. pubmed.ncbi.nlm.nih.gov
3. Headache Classification Committee of the International Headache Society. ICHD-3, 3.1 Cluster headache. ichd-3.org

If your headache is reliably brought on by neck position or long desk posture, stays on the same side, and lacks nausea and throbbing, the generator may be in your neck rather than your head.

This matters because treating the head does not fix a neck problem. People cycle through migraine medications for years without touching the actual source.

How cervicogenic headache presents

• Pain that starts in the neck or at the base of the skull and spreads forward — over the back of the head, behind the ear, sometimes to the forehead or around the eye
• Usually one-sided, and it stays on that side — it does not alternate the way migraine can
• Provoked by neck movement or position, or by pressure over the upper neck joints
• Reduced range of neck motion on the affected side
• A deep ache rather than electric jolts, and without the marked scalp tenderness of occipital neuralgia

ICHD-3 (the international classification of headache disorders) requires evidence that the headache comes from a disorder of the cervical spine or the soft tissues of the neck. It lists two ways of showing it. Either the headache develops in time with the neck disorder, or the headache is abolished (fully stopped) by a diagnostic blockade of a cervical structure or its nerve supply.¹

That second criterion is the important one. It is the whole reason diagnostic blocks exist for this condition.

Which structures refer pain into the head

The atlanto-axial joint (C1–C2)

The joint that lets you shake your head “no” carries more rotation than any other in the neck. It refers pain to the back of the head and behind the ear. It is often missed, because it sits above the levels most neck imaging and most injections address. An atlanto-axial injection reaches it, under fluoroscopy (live X-ray) with contrast dye to confirm the spot. The vertebral artery and the C2 nerve root sit right next to it, so this one is never done blind.

The upper cervical facet joints

C2–C3 in particular refers pain into the back of the head. Diagnostic medial branch blocks show whether these joints are the source.

The occipital nerves

Not a joint, but the pathway. An occipital nerve block is often the first step because it is quick, low-risk under ultrasound, and tells us something right away.

Why whiplash shows up years later

Cervicogenic (neck-driven) headache often follows a neck injury. The gap between the injury and the headache can be months. People do not connect the two. Neither does the clinician who was not told about the accident. If you have had whiplash at any point, mention it, even if it seems like ancient history.

What the treatment plan looks like

An image-guided block comes first, to find the source. If the block abolishes the pain, you have a target, and the longer-term options become reasonable. If it does not, the diagnosis moves, and you have not wasted months.

Physical therapy aimed at the upper cervical spine does much of the lasting work. Injections buy the window in which that becomes possible. Treating a neck that hurts too much to move gets you nowhere.

Everything here is placed under ultrasound or fluoroscopic guidance. With a diagnostic block, guidance is not an extra. An unguided block that fails tells you nothing, because it may simply have missed.

Common questions

Can neck arthritis on an X-ray prove my headache is cervicogenic?

No. Degenerative changes are extremely common in people with no headache at all. ICHD-3 requires either a link in timing or abolition by a diagnostic block. Imaging findings alone are not enough. See cervicogenic headache treatment.

I get neck pain with my migraines. Does that make them cervicogenic?

Usually not. Neck symptoms are very common during migraine attacks and are part of the migraine itself. The key question is whether neck movement provokes the headache, rather than just coming along with it. See migraine treatment.

What if the block only helps a little?

A partial response is truly unclear, and we treat it that way. It may mean more than one structure is contributing. Or it may mean the targeted structure is not the main generator. See image guidance for why a guided block makes a negative result trustworthy.

Is this the same as occipital neuralgia?

No. Occipital neuralgia is electric, shooting pain with a very tender scalp. Cervicogenic headache is a deeper ache that spreads from the neck and is set off by neck position. They overlap, and a block often separates them — see occipital neuralgia treatment.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 11.2.1 Cervicogenic headache. ichd-3.org

Two features point at occipital neuralgia rather than migraine. First, the pain is electric and shooting, not throbbing. Second, the scalp over the nerve is so tender that a hairbrush, a hat or a pillow hurts.

The confusion is easy to understand. Occipital neuralgia is one-sided. It can radiate (spread) forward as far as behind the eye. And it can be severe. People link all three things with migraine. But the quality of the pain and the scalp findings are different, and so is the treatment.

What occipital neuralgia actually is

The greater and lesser occipital nerves carry feeling from the back of the head. When one is irritated or compressed, the result is paroxysms (bursts) of stabbing or shock-like pain along that nerve’s path. It runs from the top of the neck, over the back of the head, and sometimes forward to the eye on the same side. Between the jolts there is often a steady background ache.

ICHD-3 describes it as unilateral or bilateral paroxysmal shooting or stabbing pain in the distribution of the occipital nerves. It comes with dysesthesia or allodynia (pain or odd feeling from a light touch) during innocuous (harmless) stimulation of the scalp. There is also tenderness over the affected nerve.¹ That last part — tenderness over the nerve — is the thing to check.

Side by side

Points to occipital neuralgia

• Electric, shooting, stabbing paroxysms — not a throb
• Pain running from the base of the skull upward, following the nerve
• Scalp allodynia: brushing hair, wearing a hat, or lying on a pillow hurts
• Pressing where the nerve emerges below the skull base reproduces the pain
• Relief when the nerve is anesthetized

Points to migraine

• Pulsating, building over minutes to hours
• Nausea, or sensitivity to both light and sound
• Made worse by routine physical activity
• Attacks lasting 4 to 72 hours
• A history of aura in some people

Scalp sensitivity is where people get caught out. That is because migraine also produces cutaneous allodynia (skin pain from light touch) during attacks. Here is the difference. In occipital neuralgia the tenderness is focal — over one nerve, present between attacks. Migraine allodynia is spread out and tracks the attack.

The block that is also a test

This is the useful part. An occipital nerve block places local anesthetic directly around the nerve. If the pain goes, that nerve was the source. That both treats the episode and settles the diagnosis. If it does not go, the pain is coming from somewhere else, and the diagnosis needs to move. Most often it moves toward cervicogenic headache or migraine.

That logic only holds if the injection actually reached the nerve. This is why we place these under ultrasound guidance. The occipital artery runs alongside the nerve. Ultrasound shows both and keeps the needle away from the vessel. So a block that fails is information, not a possible miss.

Relief commonly outlasts the anesthetic by weeks — longer than the drug alone explains. There is no fixed course of three. The gap between blocks is set by how long the last one held and by what is happening clinically.

Where the two overlap

Occipital nerve blocks are also used in migraine and in cluster headache. That can make the picture look muddier than it is. The occipital nerves meet at the same trigeminocervical relay (a pain hub) that generates migraine pain. So blocking them can modulate (turn down) a migraine even when the occipital nerve is not the main generator.

So a partial response does not confirm occipital neuralgia. A complete end to the pain in the nerve’s territory does, in someone with focal tenderness over that nerve.

Common questions

Is occipital neuralgia the same as a pinched nerve in the neck?

No, though they can coexist. Occipital neuralgia is irritation of the occipital nerve itself. Cervical radiculopathy is compression of a nerve root in the neck. Pain referred from the upper cervical (neck) joints is a third thing — see cervicogenic headache.

Do I need an MRI first?

Not usually. Doctors diagnose occipital neuralgia clinically. That means from the pain pattern, the focal tenderness and the response to a block. Imaging is used to rule out other causes when the history suggests them. See occipital neuralgia treatment.

How long does the relief last?

It varies widely between people. The anesthetic wears off in hours, but relief often lasts for weeks. We time the next block by how long the last one held, not by a schedule. See occipital nerve block.

Does the injection hurt?

The needle is fine and the injection takes seconds. Scalp numbness over the back of the head afterwards is expected and wears off over several hours. There is no sedation and you drive yourself home. See occipital nerve block.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 13.4 Occipital neuralgia. ichd-3.org

One question separates migraine from tension-type headache better than any other. Does routine physical activity make it worse? Movement makes migraine worse. It does not make tension-type headache worse.

The difference matters because migraine responds to migraine-specific treatment. Tension-type headache largely does not. A great many headaches labeled “tension” are in fact mild migraine. The wrong label leads to years of the wrong drug.

The two profiles side by side

Tension-type headache

• Both sides of the head
• Pressing or tightening quality — a band around the head, a weight on top of it — not pulsating
• Mild to moderate intensity; most people carry on working
• Not aggravated by walking or climbing stairs
• No nausea. Light or sound sensitivity may occur, but not both

Those five points are the ICHD-3 criteria almost word for word. You need at least two of four features. These are bilateral (both-sided) location, a pressing/tightening quality, mild or moderate intensity, and no aggravation by routine activity. You also need no nausea or vomiting, and no more than one of photophobia (light sensitivity) or phonophobia (sound sensitivity).¹

Migraine

• Often but not always one-sided
• Pulsating rather than pressing
• Moderate to severe — enough to interfere
• Made worse by routine physical activity, which is why people keep still
• Nausea, or sensitivity to both light and sound
• Lasts 4 to 72 hours untreated

Migraine requires at least two of the first four and at least one of the last two.² Note how the activity question appears on both lists with opposite answers. That is not a coincidence. It is the cleanest single way to tell them apart.

When the label is wrong

Does a “tension headache” ever force you into a dark room, or come with nausea, or stop you doing something you wanted to do? Then it was never a tension-type headache. Mild migraine is routinely misfiled this way. This happens especially in people who have never had a severe attack, so they have nothing to compare it against.

The other frequent impostor is cervicogenic headache — pain referred from the neck. Does your headache track with neck position, desk posture, or an old neck injury? Then that is the thread to pull. A diagnostic occipital nerve block can settle it. That is because a block that abolishes the pain tells you where it was coming from.

The rebound trap

Tension-type headache is mild enough to treat with whatever is in the cupboard. Because of that, it is the headache most likely to end in medication-overuse headache. ICHD-3 sets the thresholds precisely. The line is simple analgesics (plain painkillers) on 15 or more days a month. Or it is triptans, ergots, opioids or combination analgesics on 10 or more days a month. Either must last more than three months, in someone who already has a headache disorder.³

Cross that line and you get a daily headache. It looks like worsening tension-type headache, but it is in fact the treatment. It is common, it is reversible, and it is the first thing to address — see medication-overuse headache.

What we do for it

Frequent or chronic tension-type headache is usually not an infusion problem. It is a diagnosis problem, a rebound problem, or a neck problem. The work is finding out which. Sometimes there is real occipital (back of the head) or cervical (neck) involvement. Then an occipital nerve block is both treatment and diagnostic test. It is placed under ultrasound guidance, so a negative result can be trusted.

If the real diagnosis turns out to be migraine, the plan changes entirely — see migraine treatment.

Common questions

Can stress cause tension-type headache?

Stress is a common trigger. But tension-type headache is not simply “a headache from being stressed” and it is not psychological. And a stress trigger does not make a headache tension-type rather than migraine — stress triggers migraine too. See tension-type headache treatment.

I have headaches most days. Which is it?

Frequency alone does not decide it — both chronic migraine and chronic tension-type headache exist. What matters first is how often you are treating. That is because medication overuse changes everything downstream. See medication-overuse headache.

Does neck and shoulder tightness mean it’s tension-type?

Not necessarily. Neck symptoms are extremely common in migraine. And pain that comes from the upper cervical (neck) joints is cervicogenic headache. That is a third diagnosis with its own treatment.

Will Botox help my tension headaches?

Botox is approved and backed by evidence for chronic migraine, not for tension-type headache. Were you offered it for tension headache? Then the diagnosis is worth a second look first — see Botox for chronic migraine.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 2. Tension-type headache. ichd-3.org
2. Headache Classification Committee of the International Headache Society. ICHD-3, 1.1 Migraine without aura. ichd-3.org
3. Headache Classification Committee of the International Headache Society. ICHD-3, 8.2 Medication-overuse headache. ichd-3.org

If you have recurring “sinus headaches” without fever or discolored nasal discharge, migraine is the more likely explanation. And it is treatable. Sinus pain is one of migraine’s own symptoms. It is not evidence against it.

This is one of the most common wrong turns in headache care. People spend years on decongestants and antihistamines. They take antibiotics again and again. Antibiotics cannot touch this condition.

Why migraine feels like sinus disease

The trigeminal nerve supplies both the sinuses and the meninges (the lining around the brain). During a migraine, the trigeminal system turns on. The pain is then referred across that whole area. That includes the cheek, the bridge of the nose, and behind the eye. It truly feels like pressure in the sinuses. That is because the same nerve reports both.

Migraine also causes cranial autonomic symptoms in a substantial minority of people. These are nasal congestion, a runny nose, watering eyes. Those are the exact symptoms that make people reach for a decongestant.

Then add the weather trigger. A change in barometric pressure is a well-recognized migraine trigger. It is also what people link to sinus trouble. So the wrong blame becomes almost certain.

What actually distinguishes them

Points toward migraine

• Attacks that come and go over hours and then fully clear, leaving you well between them
• Nausea, or sensitivity to light or sound
• Pain made worse by routine physical activity such as climbing stairs
• A history of “sinus headaches” that respond to a triptan or to lying down in the dark
• No fever and no thick discolored discharge

Points toward genuine bacterial sinusitis

• Fever
• Pus-filled (purulent), discolored nasal discharge
• Symptoms that last without a break for more than ten days without getting better, or get worse after first getting better
• Facial pain and congestion that do not go away between episodes

Acute bacterial sinusitis is an illness with a beginning and an end. Migraine is a recurring attack disorder with well periods in between. The pattern over months tells them apart more reliably than any single symptom.

The diagnostic criteria are explicit about this

The International Classification of Headache Disorders is direct. Headache attributed to rhinosinusitis needs clinical, endoscopic or imaging evidence of the sinus disease. The headache must start in step with it and clear as it clears.¹ Chronic or recurring sinusitis is not accepted as a cause of recurrent headache. The one exception is when an acute flare has been demonstrated. In other words, “chronic sinus headache” as a standing diagnosis is not a recognized condition.

Migraine, by contrast, needs attacks lasting 4 to 72 hours. They need at least two of these: one-sided location, a pulsing quality, moderate or severe intensity, or getting worse with routine activity. They also need either nausea/vomiting or both photophobia and phonophobia (light and sound sensitivity).² Read those criteria against your own “sinus” attacks. The fit is often immediate.

The other thing hiding under the sinus label

One-sided facial pain with a blocked nostril and a watering eye is not migraine either, when it comes at the same hour and lasts under three hours. That is cluster headache. It is misdiagnosed as sinus disease even more often than migraine is. Are your “sinus headaches” always on the same side and always at the same time of day? Then read that page instead.

Lasting pain in the upper teeth or cheek after dental work is a third possibility. See persistent pain after dental treatment.

What treatment actually looks like

If the diagnosis is migraine, the plan is migraine-specific. Some attacks have not broken with oral medication. For those, intravenous therapy takes absorption out of the equation. Some attacks have a strong autonomic component. These are the ones that feel most “sinus-like”. For them, an SPG block targets the relay behind the nose directly, with no needle and no sedation.

Have you been treating these headaches most days with decongestants or combination painkillers? Then read headache prevention first. Frequent acute dosing can keep alive the very headache you are treating.

Common questions

My CT scan showed sinus changes. Doesn’t that prove it’s sinus?

Not on its own. Incidental mucosal thickening (swollen sinus lining found by chance) is common in people with no facial pain at all. ICHD-3 requires the headache to start in time with the sinus disease and clear as it clears.

Why did antibiotics seem to help last time?

Migraine attacks end on their own, usually within 4 to 72 hours. That is about when a course of antibiotics starts. Getting better at the same time as an antibiotic is not evidence the antibiotic caused it.

Can weather changes really trigger migraine?

A change in barometric pressure is a recognized migraine trigger. It is also what most people blame on their sinuses. That is part of why the two get confused.

I get facial pain and a runny nose with mine. Isn’t that sinus?

Cranial autonomic symptoms occur in migraine. They are prominent in cluster headache. They point at the trigeminal-autonomic system, not at infection. See cluster headache treatment.

What if I actually do have sinusitis?

Then you need it treated as an infection, and we will tell you so. This clinic treats headache disorders. A true acute bacterial sinusitis belongs with primary care or ENT. Contact us if you are unsure which you have.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 11.5 Headache attributed to disorder of the nose or paranasal sinuses. ichd-3.org
2. Headache Classification Committee of the International Headache Society. ICHD-3, 1.1 Migraine without aura. ichd-3.org

Four things separate migraine from cluster headache: which side, how long, what you do during the attack, and whether your eye and nose react on the painful side. You can check all four against your own history before you see anyone.

This matters more than most diagnostic questions, because the treatments barely overlap. High-flow oxygen aborts (stops) a cluster attack. It does nothing for migraine. Getting the label wrong costs years — a 2025 systematic review and meta-analysis of eleven studies put the average delay to a cluster headache diagnosis at 10.4 years.¹

The four discriminators

1. Which side

Cluster pain is strictly one-sided. It sits in or behind one eye or over one temple. It stays on that side within a bout. Migraine is often one-sided but does not have to be — a bilateral (both-sided) migraine is still a migraine. Being one-sided is a rule for cluster and only a tendency for migraine.

2. How long

This is the cleanest way to tell them apart. The International Classification of Headache Disorders, 3rd edition, sets the timing. An untreated cluster attack lasts 15 to 180 minutes. It reaches full intensity within minutes.² An untreated migraine attack lasts 4 to 72 hours and builds more slowly.³ If your attacks are reliably over inside three hours, migraine becomes unlikely.

Cluster also has a frequency pattern migraine does not. During an active bout, it runs from one attack every other day up to eight per day.² It often strikes at the same hour and wakes people from sleep.

3. What you do during the attack

Migraine drives people to lie still in a dark, quiet room, because movement makes it worse. Cluster does the opposite. Restlessness is part of the diagnostic criteria. People pace, rock, or press a fist into the eye socket.² Clinicians ask where it hurts far more often than they ask what you do while it hurts. The second question is often more useful.

4. Does your eye and nose react?

Cluster attacks come with cranial autonomic features (automatic body reactions in the face) on the painful side. These include a watering or reddened eye, a drooping or swollen eyelid, a constricted (small) pupil, a blocked or running nostril, facial sweating.² These are not side details — they are the reason cluster is so often mistaken for sinus disease.

Why cluster gets called sinusitis

Picture a one-sided headache with a blocked nose, a running nostril and a red watering eye. It looks exactly like an infection to almost everyone. That includes clinicians who do not see cluster often. People are treated with repeated antibiotic courses through bout after bout.

Two features break the tie. The pain is always the same side, and it keeps time — the same hour, night after night. Sinus infections do not behave that way. Maybe you have had several courses of antibiotics for “sinus headaches” that are always left-sided or always right-sided and always start in the early hours. If so, bring that history in.

A screening question set that has been validated

Researchers at Houston Methodist built a three-item screen from a larger questionnaire. It is called the Erwin Test for Cluster Headache. Their validation study included 224 people with headache disorders — 64 of whom had cluster headache. The three items together had a sensitivity of 84% (95% CI 73–92) and a specificity of 89% (95% CI 84–94).⁴ The items cover pain intensity, attack duration and autonomic features: the same three things above.

A screening tool is not a diagnosis. It is a reason to be taken seriously by the next clinician you see.

The treatments are not interchangeable

For cluster, high-flow normobaric oxygen is a first-line abortive with strong randomized evidence. It is not a migraine treatment. A greater occipital nerve block can interrupt a bout. An SPG block targets the autonomic relay (the hub) behind the tearing and congestion.

For migraine, the tools are different. Intravenous therapy is for an attack that has not broken. Botox is a preventive if you are at 15 or more headache days a month.

Dr. Gurpreet Singh Padda, MD, MBA, MHP has lived with chronic cluster headache since the age of 17. You will not have to persuade anyone here that a headache can be this bad.

Common questions

Can I have both migraine and cluster headache?

Yes, and it is not rare. Having one does not exclude the other. A person can have separate attack types with different treatment plans. Track them separately in a diary — see migraine treatment and cluster headache treatment.

Does a normal MRI rule out cluster headache?

No. Cluster headache is a clinical diagnosis made from the attack pattern, not from imaging. Imaging is used to rule out other causes. A normal scan is the expected finding. See when a headache actually needs a scan.

If oxygen helps, does that confirm cluster?

It is supportive, not proof. High-flow oxygen stopping attacks fits cluster well, and it does not treat migraine — but the flow rate and mask have to be right, or the test is meaningless. See oxygen therapy.

My headache is one-sided but lasts all day. Is that cluster?

Unlikely, on duration alone. Untreated cluster attacks run 15 to 180 minutes. An all-day one-sided headache fits migraine, cervicogenic headache or occipital neuralgia better.

What should I bring to the appointment?

Bring a month of attack times, how long each lasted, which side, and every medication you took, including over-the-counter. How often you are treating is one of the most useful facts you can give us — see contact.

When it is an emergency

None of the above applies to certain headaches. That means a headache that reaches maximum intensity within seconds, a headache with fever and a stiff neck, any weakness, numbness, trouble speaking, vision loss or confusion, or a headache after a head injury. Those need an emergency department. Headache Express is an outpatient clinic, not an emergency room — call 911.

Sources

1. Peng K-P, et al. Cluster headache diagnostic delay and its predictors: a systematic review with a meta-analysis. The Journal of Headache and Pain, 2025. link.springer.com
2. Headache Classification Committee of the International Headache Society. ICHD-3, 3.1 Cluster headache. ichd-3.org
3. Headache Classification Committee of the International Headache Society. ICHD-3, 1. Migraine. ichd-3.org
4. Parakramaweera R, Evans RW, Schor LI, et al. A brief diagnostic screen for cluster headache: creation and initial validation of the Erwin Test for Cluster Headache. Cephalalgia, 2021. PMID 34148408. pubmed.ncbi.nlm.nih.gov