Most of us experience a headache now and then. But are there instances when we need to take that headache more seriously? 

Most headaches are not dangerous and can be caused by a variety of factors, such as tension headaches, which may be triggered by stress, hunger, lack of sleep, caffeine withdrawal, medication overuse, or abruptly stopping the use of pain-relieving medications like ibuprofen or acetaminophen. Sinusitis, as well as migraine, are also common causes of headaches.

“Headaches that occur later in life in someone who was never bothered by them earlier, are disruptive or won’t go away with acetaminophen or a nonsteroidal anti-inflammatory, is cause for concern and may be a sign of a more serious condition,” says Nebraska Medicine neurosurgeon Mithun Sattur, MBBS. “Unless you have known migraine that are being medically managed with your provider and you know your individual headache pattern, don’t dismiss severe, frequent or lingering headaches. Talk to your provider and get it checked out.”

Some of the most concerning causes for a severe headache include stroke or a brain aneurysm, notes Dr. Sattur. Typically, these kinds of headaches come on suddenly and are very severe.

Is it a migraine headache?

But how do you know that it’s not a migraine? Migraines usually develop at a younger age and rarely begin later in life, says Dr. Sattur. Migraine sufferers often experience a warning sign, known as an aura, before the headache comes on. This can involve flashes of light, blind spots or, less commonly, tingling on one side of the face, arm or leg. This is always temporary and, if prolonged, may need to be investigated at once.

Symptoms of a migraine include:

• Aura
• Severe throbbing or a pulsing sensation on one side of the head.
• Nausea, vomiting
• Extreme sensitivity to light and sound

Stroke-related headache

Stroke-related headaches are typically associated with a specific type of stroke called hemorrhagic stroke, which causes bleeding into the brain. This type of stroke is more common among individuals with uncontrolled or poorly controlled high blood pressure. The pressure causes blood vessels in your brain to weaken, rupture and bleed, causing a severe headache.

The headache may be localized to one side of the brain in smaller hemorrhages.  With large bleeds, it may cause a “thunderclap” headache.  “A thunderclap headache is one of the most terrible headaches known to man,” Dr. Sattur says. “It comes on severely and suddenly with no warning and typically affects the entire head. Patients have reported that they feel a sense of impending doom.”

Symptoms of a large hemorrhagic stroke include:

• Severe headache that comes on suddenly with no warning
• Usually affects the entire head
• Slurred speech
• Sudden numbness or weakness in the face, arm or leg, especially on one side of the body
• Confusion
• Trouble speaking
• Difficulty understanding speech
• Vision problems in one or both eyes
• Dizziness or loss of balance

Risk factors for hemorrhagic stroke include:

• High blood pressure
• Older age
• Excessive alcohol intake
• Smoking

“You should go to an emergency room immediately as time is everything with a stroke,” says Dr. Sattur. The hemorrhagic stroke occurs deep in the brain. It can affect critical structures that control speech, memory and movement. The longer you delay treatment, the greater your risk of suffering severe damage to the brain.

Brain aneurysm-related headache

A brain aneurysm is a bulge or weak area in a blood vessel in or around the brain. It is typically known to trigger a thunderclap headache.

Brain aneurysm-related headache symptoms include:

• Severe neck stiffness
• Nausea and vomiting
• Pain around or behind the eyes
• Loss of consciousness

Leaking aneurysm

A brain aneurysm may start with small ‘microbleeds’ or warning leaks. These lower-level headaches  are not quite as severe as a thunderclap headache but can come on suddenly. If unrecognized, they may often be followed by a more severe rupture.

Unruptured aneurysm

An unruptured aneurysm may not have any symptoms. However, a larger aneurysm pressing on nerves and brain tissue may cause symptoms.

Symptoms of a large, unruptured aneurysm include:

• Progressive headaches
• Numbness or weakness on one side of the face
• A change in vision or double vision, dilated pupil

“A symptomatic brain aneurysm is a medical emergency,” says Dr. Sattur. “Almost one-third of people die shortly after the rupture. Anyone suspected to have a ruptured or leaking aneurysm should go to the ER immediately for detection and treatment because there’s a significant chance it will rupture again.”

Nebraska Medicine neurosurgeons perform several minimally invasive endovascular and microsurgical techniques that can repair a promptly detected ruptured aneurysm. “We can apply many of the same techniques and more to treat people with unruptured aneurysms as well,” notes Dr. Sattur.

Risk factors for brain aneurysm formation and rupture:

• Cigarette smoking
• Drug use, especially cocaine use
• High blood pressure
• Family history of brain aneurysms
• Older age

In rare cases, you could experience a stroke-related headache caused by accidental trauma or manual manipulation of the neck area. Trauma or manual manipulation may cause an internal tear to one of the arteries in the neck. “This is very rare but is known to happen and is termed a dissection,” notes Dr. Sattur.

“The bottom line – don’t dismiss a severe, sudden or lingering headache,” says Dr. Sattur. “The longer you delay evaluation, the more damage you could experience if it is indeed due to a stroke or aneurysm.”