Brief Communication

Water-Deprivation Headache: A New Headache

With Two Variants
Joseph Norman Blau, MD; Christian Alexander Kell, MD; Julia Maria Sperling

Objective.To describe a new type of headache induced by water deprivation.

Background.Two medical students experienced headache over the previous 7 (C.A.K.) and 9 (J.M.S.) years
when deprived of drinking water. In a tutorial on headache, they mentioned this precipitant, not recognized by the
tutor (J.N.B.) or described in the medical literature. Dialysis and post-alcohol headaches are widely attributed to
dehydration, but simple water deprivation has not been documented as a headache precipitant.
Methods.Family members, colleagues, and acquaintances were asked whether they experienced a headache
when deprived of fluids. If they had, information was obtained regarding the location and quality of the headache,
whether activity or posture influenced the pain, and what amount of fluid and time was needed to relieve symptoms.
Results.Approximately 1 in 10 interrogated subjects experienced water-deprivation headache, aching in the
majority and accentuated by head movement, bending down, or walking. The 34 subjects were divided into 2 groups
according to the time taken to relieve the headache by drinking water: total relief within 30 minutes by drinking 200
to 1500 mL (mean, 500) occurred in 22 subjects, and within 1 to 3 hours by drinking 500 to 1000 mL (mean, 750) in
11 subjects; 1 subject required sleep in addition to fluid intake. Surprisingly, the Internet revealed many references
to water deprivation inducing headaches.
Conclusions.Water-deprivation headache is common, recognized by the public, but not described in the
medical literature. Here we delineate it as a primary headache, postulating that the pain arises from the meninges;
that the brain is also involved is indicated by impaired concentration and irritability, although not studied in detail in
this preliminary survey. We speculate that water deprivation may play a role in migraine, particularly in prolonging
attacks. Further studies of serum osmolality could prove illuminating.
Key words: headache, water deprivation, dehydration
(Headache 2004;44:79-83)

Deydration is one of a number of factors provoking post-alcohol or renal dialysis headaches.1,2 A seemingly common headache due to a single precipitating
factorwater deprivation, is herein reported. During
a tutorial on headache, lack of water intake inducing
a headache was not mentioned by the tutor (J.N.B.),
but was raised by 2 of 5 medical students (J.M.S. and
C.A.K.) from personal experience since their teens.

Consulting the Internet revealed many references to

water deprivation inducing headache. Because pure
water-deprivation headache is well recognized by the
public, but not by the medical profession, we decided
to study the condition.

INITIAL CASE HISTORIES

The 2 students histories that initiated the study
are presented first.
Case 1.A 23-year-old female medical student (J.M.S.) experienced her first water-deprivation
headache at aged 16 years. It recurred about once a
month. With inadequate fluid intake, her first symptom was a feeling as if the brain is moving, provoked
by sudden head movement. She then developed a biparietal headache, which extended toward but did not

From The National Hospital for Neurology and Neurosurgery,

London, UK (Dr. Blau) and the Departments of Neurology (Dr.
Kell) and Psychiatry and Psychotherapy (Miss Sperling), Johann
Wolfgang Goethe University, Frankfurt-am-Main, Germany.
Address all correspondence to Dr. Joseph N. Blau, The National
Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
Accepted for publication July 24, 2003.

79

80
reach the vertex; the pain, a deep-seated ache, was
accentuated by head movement or by jolting when
traveling in a car, and was lessened by keeping her
head still. Drinking a glass of water alleviated this mild
headache in 10 to 15 minutes.
Once or twice a year, a longer-lasting and more
severe headache would occur after prolonged dehydration. She recalled a tour of Rome: having been
warned about the lack of toilets, she took no fluid with
breakfast at 6:30 AM. Five hours later, she developed a
headache with the above characteristics, which became
steadily more severe and was markedly increased by
jolting of the coach and by each step when walking.
She had no nausea and ate normally. Arriving back at
the hotel at 8 PM she looked pale, had the normal endof-the-day hunger and ate a full meal; she drank half a
liter of water without resolving the headache and took
one aspirin tablet before going to bed. When lying still
in bed, pulsations in the temples accentuated the head
pain. She attained sleep in about 20 minutes, slept for
13 hours5 hours longer than usual, and awoke the
next morning pain-free, feeling perfectly normal.
She occasionally had other headaches due to insufficient sleep or being in an ill-ventilated room. She
had not had migraine. Her mother also experienced
water-deprivation headache (subject 4, Table 2).
Case 2.A 24-year-old male medical student
(C.A.K., now a qualified doctor) experienced his first
water-deprivation headache at aged 15 years. It would
recur every 2 to 4 weeks. The first symptom was
a lightheadednessa sensation of unsteadiness, accompanied by impaired concentration and unfocussed
near and distant vision, without headache; these symptoms lasted seconds and could be suppressed by concentrating. Drinking water resolved the symptoms in 5
to 10 minutes. If unable to drink (while hiking or holding a retractor during an operation), a deep-seated,
occipital, dull ache (2 on a 1 to 10 severity scale) developed, accentuated by bending forward, sneezing, or
lifting heavy objects. Drinking water at this stage relieved the headache in 10 to 15 minutes. If still unable
to obtain water, a different type of headache developed. It was situated in the temple (usually left sided),
extended to the midline, and was throbbing in quality;
the pain was rated 5 on a 1 to 10 scale. The headache
caused him to stop reading, he had impaired concen-

January 2004
tration, became irritable, and looked pale, although he
was able to continue holding a retractor when assisting
at an operation. He did not take analgesics, but 750 mL
of water provided 95% relief in 15 to 20 minutes. Pallor persisted although he was uncertain for how long,
and he retained dizziness and a lightheaded sensation
for the remainder of the day, yet he was able to eat and
work normally.
In the past, he had alcohol hangover headache on
2 occasions. He also experienced mild headaches after insufficient sleep and a mountain headache at 5400
meters without nausea or vomiting. He had not had
migraine. His mother (subject 7, Table 2) and grandmother had dehydration headache, hence the standard
family treatment for headache was, Drink some water.

METHODS AND RESULTS

Family members, colleagues, and acquaintances
were asked whether they ever experienced a headache
when fluids were unavailable. About 1 in 10 had experienced such a headache, enabling us to collect 34 subjects in 6 weeks. Those who ate food at the same time
as quenching their thirst were excluded because they
might have confused a hunger headache with one arising from water deprivation; however, 2 subjects could
clearly distinguish these 2 headache types and were
included (subject 11, Table 1 and subject 6, Table 2).
One glass was assessed to contain 250 mL of water.
Of the 34 subjects, 24 were women and 10 were
men. Ages ranged from 20 to 76 years (mean, 42). Nine
subjects were doctors; 4, senior medical students; 6,
qualified nurses; and 15 had no medical training.
We divided our subjects into 2 groups according
to the time taken to resolve headache after drinking
water: headaches totally resolved in 30 minutes or less
(mean, 19 minutes) by drinking 200 to 1500 mL (mean,
500) of water in 22 subjects (Table 1); headaches lasted
longer taking 1 to 3 hours (mean, 2) to disappear completely after drinking 500 to 1000 mL (mean, 750) of
water in 11 subjects (Table 2). One subject (No. 10,
Table 2) required sleep in addition to water to resolve
the headache, as in case history 1.
A brief survey on the Internet revealed many references to headache arising from inadequate fluid intake, with advice to sauna bathers, pilots, airplane

Headache

81
Table 1.Subjects With Short-Lasting Water-Deprivation Headache

No.

Age, y
Sex

Site

Superficial or
Deep

Quality

Accentuation

Relief,
min

Fluid
Intake, mL

Comment

1
2

73 F
26 F

Frontal
Generalized

?
?

Feels heavy
Steady ache

?
?

5
5-10

200
500

76 F

Some

600

4
5

32 F
51 F

Frontal
occipital
Generalized
Frontal

Feel faint if
prolonged
PMH: migraine

Deep
?

?
?

10
20-30

1000
500

PMH: migraine

6
7
8
9
10
11
12
13
14
15
16
17
18

47 F
35 F
60 F
36 F
36 F
20 F
72 M
64 F
38 F
30 M
73 M
26 F
69 M

Frontal
Occipital
Frontal
Generalized
Occipital
Frontotemporal
Frontal
Frontal
Generalized
Temporal
Frontal
Generalized
Frontal

Deep
Deep
Deep
Superficial
Superficial
Deep
Superficial
Superficial
Superficial
Deep
?
Deep
?

?
Throbbing
Steady ache
Tightness
Ache
Pressure
Ache
?
Pressure
Dull pain
Throbbing
Pressure
Dull ache

20
5-10
20
10
30
20
15-30
30
30
5-10
30
20-30
10

500
500
200
300
400
250
500
300
500
750
500
1500
200

PMH: migraine 2
PMH: hunger HA

PMH:migraine

Medical student

19

55 F

Frontal

Ache

?
Head movement,
bending
Bending, jogging
Bending
Exercise
Walking
Bending
Bending
Nil
Nil
Nil
?
Exertion, jumping
Head movement
Jumping, head
movement
Nil

15

300

20
21
22

27 M
34 M
25 M

Frontal
Temporal
Temporal

Deep
Deep
Deep

Throbbing
Throbbing
Dullthrobbing

?
?
Head movement

30
15
20

500
500
750

HA started
in menopause
500 mg aspirin

Medical student

? indicates uncertainty; PMH, past medical history; HA, headache.

Doctor.
Nurse.

passengers, as well as an article in the journal, Outdoor

Adventures entitled Its not just waterits headache
medicine.3

COMMENTS
What appears to be a common headache arising
from a deficiency of a single dietary elementnamely
water, relieved by drinking fluid is described.
Water-deprivation headache is not mentioned in
the International Headache Society classification of
head and facial pain,4 or in standard textbooks on
headache,5-7 although dehydration headaches, presumably due to multiple factors, are listed under alcohol withdrawal and dialysis headache.7 Hence, we were
surprised by the ease with which we collected 34 subjects. Perhaps this type of headache has not previously

been described because subjects know that drinking

water gives rapid headache relief and do not seek medical advice.
Possible Mechanisms.Site of Origin of
Headache and Associated Symptoms.An intracranial origin is suggested by pain accentuation
with sudden head movement, bending down, or head
jolt, based on human observations during histamine
headaches and migraine.8,9 Further, it is accepted that
nociceptive nerve endings are localized in the human
dura adjacent to intracranial venous sinuses and
meningeal arteries, the brain itself being painless.10,11
Brain involvement in addition to the meninges,
however, is indicated in some of our subjects by
impaired concentration, irritability, nausea, and
pallor.

82

January 2004
Table 2.Subjects With Prolonged Water-Deprivation Headache

No.

Age, y
Sex

Site

Superficial
or Deep

Quality

Accentuation

1
2
3
4
5

26 F
33 F
40 M
50 F
22 F

Frontal
Occipital
Generalized
Temporal
Frontotemporal

Superficial
Deep
Superficial
Deep
Deep

Ache
Feels heavy
Gripping
Dull ache
Pressurethrobbing

32 F

Generalized

Deep

Pressurethrobbing ?

7 61 F

Head shaking
Watching TV
Nil
?
Head movement

Relief,
Fluid
min Intake, mL

2-3
2-3
2-3
1-2
2-3

500-1000
500
400
500
500

2-3

1000

Bitemporal or
occipital
8 38 M Retro-orbital
9 36 F Temporal
10 34 M Occipital

Deep

Dull ache

Walking

500-1000

Deep
Deep
Deep

Ache
Dullthrobbing
Throbbing

Standing up
?
?

2
1
2

1000
500
1000

11
12

Deep
Dullthrobbing
Superficial Pressure

1-2
2

1000
1000

32 F
29 F

Temporal
Frontal

?
?

Comment

PMH: premenstrual HA
PMH: hunger HA
HA & dizziness
Medical student,
HA & dizziness
Medical student,
PMH: hunger HA
PMH: migraine
Needs analgesic
PMH: migraine
Nausea w/HA,
needs to sleep
Nausea w/HA
Nausea w/HA,
500 mg aspirin

PMH indicates past medical history; HA, headache, ?, uncertainty.

Nurse.
Doctor.

Nature of the Disturbance.The most likely cause

of the headache and other symptoms is intracranial
dehydration affecting the meninges and brain, each
perhaps having different sensitivities in different subjects. Twenty-fourhour water deprivation in humans
showed decreased plasma volume and extracellular
fluid, with increased plasma osmolality (2.7%), sodium
concentration (2.1%), and renin activity (82%); rehydration normalized osmolality and sodium concentration within 15 minutes and renin activity within
60 minutes.12 Animal experiments with prolonged dehydration revealed larger changes in plasma osmolality and sodium concentration, accompanied by lowered intracranial pressure and traction on the venous
sinuses.13-15 Is it possible in our subjects with milder
hypertonicity if some of these mechanisms played a
role?
The separation into 2 groups by the timing of
symptom resolution suggests a progression of severity
in meningeal and cerebral involvement. It seems likely
that headache severity, as well as symptom resolution, depends on the duration of water deprivation. An
analogous time course occurs with food deprivation: a

hunger headache usually resolves within minutes after starting to eat, but a prolonged headache, such as
migraine, can occur in predisposed subjects when food
intake is delayed.16 It is worth noting that in both of
our groups some subjects had migraine, although none
developed migraine due to water deprivation. Since
completing this study, however, 2 migraineurs spontaneously and 3 others on direct questioning indicated
that insufficient fluid intake could provoke some of
their attacks; we therefore consider that this precipitant needs further study in migraine. We also wonder if
water deprivation might play a role in the persistence
of migraine. Serial plasma osmolality during attacks
could support or refute these hypotheses.
Our study does not indicate the prevalence of
water-deprivation headache, which would require an
epidemiological study. Both presenting cases, however, had mothers affected by the same type of
headache, raising the possibility of a familial predisposition.
A headache questionnaire of 327 medical students
included a section where other headaches were
requested.17 Of the 62 who completed this section,

Headache
5 mentioned dehydration. Whether these headaches
were due to water deprivation is unclear as they could
have been referring to post-alcohol headache, which
had affected 38% of the students.
In conclusion, we delineate a new headache due
to a single precipitantinsufficient water intake. The
pain can be localized or generalized, is accentuated
by head movement, and is relieved by drinking water within 30 minutes in the majority or within several
hours in the remainder. The underlying mechanisms
warrant further clinical and investigative studies along
with possibly further studies into the water responsiveness of other headaches, thereby perhaps extending
our understanding of headache pathophysiology and
even treatment.

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