Headache Behind the Eyes: Understanding the Causes

By Matthew AdamsReviewed by Danielle Ellis, B.Sc.

Different types of headaches
Common causes
Serious medical conditions
Diagnostic approaches
Treatment options
When to seek medical advice
References 
Further reading 

Headaches are an uncomfortable sensation experienced by a vast number of people, and this pain sometimes manifests behind the eyes. While this sensation is often due to more benign reasons, numerous more serious conditions produce the same feeling.

This article describes both the more common and severe conditions, alongside how to recognize the difference between them.

Different types of headaches

Headache describes an uncomfortable sensation whereby an individual feels pain in their head. While seemingly simple, headaches come in multiple different subtypes, separated by duration and pain level.

Tension headaches are the most common type of headache experienced by individuals, with a study showing a prevalence of 38.3% within one year. ¹ Typically presenting as a dull, steady ache, these headaches often last around half an hour. ²

Migraines are another subtype of headache. This variety of headache typically lasts one to two hours and affects one side of the head. Often, before or sometimes during the pain portion of the migraine, there will be an “aura.” Aura refers to several neurological symptoms, such as an aversion to sounds or changes in vision, like bright spots. ³

All together, rarer are cluster headaches. These headaches are thought to affect only around 1 in 1000 people and are incredibly painful, often described as a stabbing pain affecting one side of the head. ⁴ These bouts last under three hours, sometimes presenting with restlessness and autonomic disturbances. ⁵

Although all three of these headaches present with slight differences, all three of them sometimes present with pain behind the eyes. Although the exact cause of this pain is currently unknown, researchers speculate that it may derive from blood vessels around the eye.

Research has shown that in patients with ≥5 episodes of migraines per month, blood vessels around the eye dilate. The same research showed that in cases of unilateral migraine (affecting one side of the head), this same side has dilation of the retinal blood vessels. ⁶ Vasodilation is thought to play a role in the production of pain in migraines. ⁷

Common causes

A common cause of headaches that may be on the rise is digital eye strain, a condition that can arise from prolonged periods of digital screen usage. This can present with a headache, commonly felt behind the eyes, blurred vision, and sensitivity to light. ⁸

Sleep deprivation has also been shown to induce headaches in some individuals. With 1-3 hours of sleep lost for 1-3 nights, it is enough to generate a headache lasting between an hour and all day. ⁹

Infections may also lead to headaches, one common example being sinusitis (a sinus infection). Typically presenting with a swelling of the sinuses, which may feel like a build-up of pressure in the forehead, cheeks, and nose. This build-up of pressure in a sinus can cause pain, which feels like a headache. ¹⁰

Serious medical conditions

While the cause of pain behind the eyes is normally due to a more benign source, several more serious conditions can lead to the manifestation of this phenomenon. Glaucoma is one such cause of eye pain, describing a group of conditions that injure the optic nerve (the nerve that transmits visual information from the eye). This damage to the optic nerve may lead to pain and inflammation around the eye. ¹¹

A brain aneurysm is an enlarging of a blood vessel, typically due to a thinning of the blood vessel walls. ¹² As an aneurysm develops in size, it may press against other areas of the brain, leading to the presentation of a variety of neurological symptoms. Visual symptoms have been associated with intracranial aneurysms. ¹³

This increase in pressure may trigger artery pain receptors in the front of the head, leading to pain behind the eyes. This pathogenesis has been observed to cause pain in a variety of hemorrhage types. ¹⁴

Finally, multiple sclerosis (MS) may lead to a headache behind the eyes. In MS, dysfunction of the immune system leads to the attacking and demyelinating of nerves. As MS can affect the optic nerves, it can present with a variety of optic symptoms, such as vision loss. ¹⁵ This optic nerve damage and inflammation can lead to eye pain.

Diagnostic approaches

Differentiating between the causes of pain behind the eyes can be achieved through a mixture of physical examination, vision tests, and advanced imaging techniques. Determining whether a patient is suffering from migraines is often conducted only using the patient’s symptoms and family history. ¹⁶

When assessing for glaucoma, physicians will often evaluate for intraocular pressure, alongside looking for visual field deficits. ¹¹ Imaging is not typically used when it is suspected a patient may have glaucoma or migraines, instead being employed when an aneurysm or MS is suspected.

In a suspected brain aneurysm, an MRI or CT angiography is performed, which uses a specially formulated dye to mark the area affected by the aneurysm. ¹⁷ Through this tool, clinicians can also tell if the aneurysm has ruptured, allowing for accurate and rapid treatment. ¹⁷

MS may be diagnosed using a combinatorial approach. Vision tests can indicate the presence of optic neuritis through loss of vision, alongside nystagmus and diplopia. ¹⁸ MRI imaging may also be used as an additional tool in diagnosis, allowing the visualization of damage to the optic nerve in MS. ¹⁹

Treatment options

Typically, for tension headaches and migraines, over-the-counter pain relief is considered the first line of treatment. These over-the-counter drugs are productive, low cost, and have fewer side effects, making them a preferred choice for physicians. ²⁰

However, over-the-counter medication may only be effective for mild-moderate migraines, sometimes requiring other treatments. OnabotulinumtoxinA is an FDA-approved treatment that may benefit individuals suffering from migraines and headaches. Botulinum toxin may block the release of neurotransmitters involved in pain. ²¹

In cases of pain behind the eyes brought on by more common headaches, several lifestyle changes could lower the frequency. In cases due to DES, following the 20-20-20 rule (looking away for 20 seconds, every 20 minutes, at an object 20 feet away) has been observed to decrease DES frequency. ²²

As mentioned earlier, sleep deprivation can lead to headaches. ⁹ Therefore, increasing sleep length and quality may help individuals avoid headaches. Through these lifestyle changes, it may be possible to lower the frequency of headaches without turning to medical intervention.

When to seek medical advice

Although the frequency of more serious medical conditions is relatively low, it is still important to recognize signs where further investigation is warranted. Neurological symptoms that are constant or long-lasting are an indication of a potentially more serious condition.

In common causes of headaches that present with neurological symptoms, such as migraines, neurological symptoms only last for shorter periods. Typically occurring over less than an hour, the aura lasts up to a week at maximum. ²³

Extremely sudden onset of pain or visual symptoms may also be an indicator of a more serious condition, such as a ruptured aneurysm. Unruptured aneurysms may not present with symptoms. However, a rupture may lead to the sudden onset of pain. ²⁴ In such cases, seeking immediate professional help is of the utmost importance.

Understanding how these forms of headaches behind the eyes arise and the underlying mechanisms is incredibly important. This is not only to inform potential treatment options but also to allow individuals to recognize when to seek medical treatment. It is, therefore, important for individuals to pay attention to their symptoms and refer themselves to healthcare providers when necessary.

References

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2.       NHS. Tension-type headaches. https://www.nhs.uk/conditions/tension-headaches/. Published 2022. Accessed May 21, 2024.

3.       Baloh RW. Neurotology of Migraine. Headache J Head Face Pain. 1997;37(10):615-621. doi:10.1046/j.1526-4610.1997.3710615.x

4.       Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: A meta-analysis of population-based studies. Cephalalgia. 2008;28(6):614-618. doi:10.1111/j.1468-2982.2008.01592.x

5.       Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. Cephalalgia. 2004;24.1:9-160.

6.       Unlu M, Sevim DG, Gultekin M, Baydemir R, Karaca C, Oner A. Changes in retinal vessel diameters in migraine patients during attack-free period. Int J Ophthalmol. 2017;10(3):439-444. doi:10.18240/ijo.2017.03.18

7.       Jacobs B, Dussor G. Neurovascular contributions to migraine: Moving beyond vasodilation. Neuroscience. 2016;338(3):130-144. doi:10.1016/j.neuroscience.2016.06.012

8.       Kaur K, Gurnani B, Nayak S, et al. Digital Eye Strain- A Comprehensive Review. Ophthalmol Ther. 2022;11(5):1655-1680. doi:10.1007/s40123-022-00540-9

9.       Blau JN. Sleep deprivation headache. Cephalalgia. 1990;10(4):157-160. doi:10.1046/j.1468-2982.1990.1004157.x

10.     Jones NS. Sinus headaches: avoiding over- and mis-diagnosis. Expert Rev Neurother. 2009;9(4):439-444. doi:10.1586/ern.09.8

11.     Bhowmik D, Kumar KPS, Deb L, Paswan S, Dutta  a S. Glaucoma - A Eye Disorder. Its Causes , Risk Factors , Prevention and Medication. WwwThepharmajournalCom. 2012;1(1):66-82.

12.     Purvin VA. Neuro-ophthalmic Aspects of Aneurysms. Int Ophthalmol Clin. 2009;49(3):119-132. doi:10.1097/IIO.0b013e3181a8d586

13.     Park JH, Park SK, Kim TH, Shin JJ, Shin HS, Hwang YS. Anterior communicating artery aneurysm related to visual symptoms. J Korean Neurosurg Soc. 2009;46(3):232-238. doi:10.3340/jkns.2009.46.3.232

14.     Smetana GW, Shmerling RH. Does this patient have temporal arteritis? JAMA. 2002;287(1):92-101. doi:10.1001/jama.287.1.92

15.     Blanco LF, Marzin M, Leistra A, Van Der Valk P, Nutma E, Amor S. Immunopathology of the optic nerve in multiple sclerosis. Clin Exp Immunol. 2022;209(2):236-246. doi:10.1093/cei/uxac063

16.     Cutter EE. How to Diagnose Migraine. Am Headache Soc. 2021.

17.     NHS. Diagnosis: Brain Aneurysm.

18.     Balcer LJ, Miller DH, Reingold SC, Cohen JA. Vision and vision-related outcome measures in multiple sclerosis. Brain. 2015;138(1):11-27. doi:10.1093/brain/awu335

19.     Hickman SJ. Optic Nerve Imaging in Multiple Sclerosis. J Neuroimaging. 2007;17(s1). doi:10.1111/j.1552-6569.2007.00136.x

20.     Peck J, Urits I, Zeien J, et al. A Comprehensive Review of Over-the-counter Treatment for Chronic Migraine Headaches. Curr Pain Headache Rep. 2020;24(5):19. doi:10.1007/s11916-020-00852-0

21.     Ashkenazi A, Blumenfeld A. OnabotulinumtoxinA for the Treatment of Headache. Headache J Head Face Pain. 2013;53(S2):54-61. doi:10.1111/head.12185

22.     Talens-Estarelles C, Cerviño A, García-Lázaro S, Fogelton A, Sheppard A, Wolffsohn JS. The effects of breaks on digital eye strain, dry eye and binocular vision: Testing the 20-20-20 rule. Contact Lens Anterior Eye. 2023;46(2). doi:10.1016/j.clae.2022.101744

23.     Viana M, Sprenger T, Andelova M, Goadsby PJ. The typical duration of migraine aura: a systematic review. Cephalalgia. 2013;33(7):483-490. doi:10.1177/0333102413479834

24.     Wiebers DO. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362(9378):103-110. doi:10.1016/S0140-6736(03)13860-3

Further Reading

• All Headache Content
• What is a Headache?
• Types of Headaches
• Headache Causes and Triggers
• Using a Headache Diary