Identifying factors that precipitate or aggravate headache attacks is useful in establishing a diagnosis and implementing a treatment program. Recognizing triggers helps patients avoid precipitants. Alcohol, a newly prescribed drug, bright lights, fatigue, loss of sleep, hypoglycemia, stress, food additives, and certain drugs can provoke migraine. Migraine is often triggered by menstruation and relieved by pregnancy. Exercise or orgasm can trigger a migraine or result in the rupture of an aneurysm. Head trauma can both cause and trigger headache.

Headache Relieving Factors
Identifying the factors that ameliorate the discomfort of the headache and the associated symptoms may provide useful diagnostic and therapeutic information. Migraineurs commonly volunteer that they must retire to a dark quiet room and lie motionless to obtain relief; many patients find that sleep will clear their attacks. Not infrequently, pressing on the superficial temporal artery brings relief but only during the period of compression. Hot or cold compresses are often applied. Cluster-headache patients note that sitting upright, rocking in a chair, pacing to and fro, or engaging in vigorous movement seems to lessen the pain. Tension-type headache may be alleviated by relaxation, rest, or sleep.

Effects of Position and Body Movement
In many instances, migraine is made worse by assuming a horizontal position and is relieved by an erect position. It is often made worse by ascending stairs, moving about rapidly, or lifting. Sitting quietly in an upright position often proves to be most comfortable. The recumbent position may at first intensify the headache associated with nasal and paranasal disease, but subsequently the headache subsides. A sudden change in position, usually from the sitting to the recumbent position, may intensify the headache of brain tumor. Unlike migraine headache, the headache of brain tumor is often worse when the patient is in the upright position. The head-down position aggravates most headaches, except those due to spinal drainage and occasionally those associated with brain tumor.

Straining at stool and coughing increase all but tension-type headache and headaches due to spinal drainage. Sharp flexion or extension of the head often reduces the intensity of post-lumbar puncture headache, whereas jugular compression increases the headache.

A major criterion that can be used in the diagnosis of cluster headache is the patient’s behavior during the attack. Pacing, walking, sitting, and rocking are activities that are considered pathognomonic of this disorder. Frantic activity may occur. No other primary headache disorder is associated with such behavior.

Editors: Silberstein, Stephen D.; Lipton, Richard B.; Dalessio, Donald J.