Scalp pain from hairstyles: when to worry

Anyone who has had tight braids or spent the day with a high ponytail knows the feeling: when you let your hair down, the root hurts, the scalp is tender to the touch and, sometimes, there is a headache. Many people think this is normal, especially in the first days after having braids put in. It is not.

Pain is the first sign that the hairstyle is pulling too much. Ignoring it, repeatedly, is the road to traction alopecia. And there is another important point: not all scalp pain comes from the hairstyle. Some causes, such as giant cell arteritis in people over 50, need medical attention the same day.

Why a hairstyle hurts

External traction headache

The International Classification of Headache Disorders (ICHD-3) recognises a distinct type of headache, external traction headache, formerly called "ponytail headache". Its characteristics are:

• appears only during prolonged traction on the scalp (ponytail, bun, braids, extensions, headbands);
• is more intense where the hair is pulled, although it can spread across the head;
• goes away within an hour of removing the traction.

The pain results from the stretching of the soft tissues and nerves of the scalp, which is very rich in nerve endings. It does not cause damage in itself, but it is a warning: the traction is excessive.

The inflammation around the follicles

When the tension continues for days or weeks, as with braids and extensions, the follicles begin to become inflamed. At that point the pain no longer goes away when you let your hair down: the scalp is sore and warm, with red dots or small spots around the hairs, especially at the margins. This is the early stage of traction alopecia, still reversible. See Traction alopecia: what it is and how to recognise it.

Pain as a predictor of risk

The review by Billero and Miteva (2018) states that, in one of the studies cited, only about 19% of people with traction alopecia said they had never had pain during or after having their hair styled. Specialists sum up the message in one sentence: tolerating the pain of a hairstyle is risking hair loss.

Pain that warns and pain that alarms

A well-done hairstyle should not hurt. If it hurts, it is too tight.

When the pain is not from the hairstyle

The scalp can hurt for many other reasons. If the pain appeared unrelated to hairstyles, or does not go away when you let your hair down, consider these possibilities.

Giant cell arteritis (temporal arteritis)

It is an inflammation of the arteries, especially at the temples, which almost exclusively affects people over 50. The signs include a new headache, usually at the temples, a scalp that is tender to the touch (for example, when combing or resting your head on the pillow), jaw pain when chewing or speaking, changes in vision, a mild fever and tiredness. Without prompt treatment it can cause permanent loss of vision. If you have these symptoms, seek medical help the same day (Mackie et al., 2020).

Shingles (herpes zoster)

Pain, burning or tingling on one side of the head only, in a band, followed a few days later by red patches and blisters. When it reaches the forehead or the area around the eye, it requires prompt assessment. Antiviral treatment works best in the first days.

Folliculitis and infections

Painful spots around the follicles, caused by bacteria, fungi (tinea) or irritation. See Round patch in the hair: when it is worth assessing on tinea.

Scarring alopecias

Lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans can cause pain, burning and itching, with progressive hair loss. They need early diagnosis and treatment.

Trichodynia

This is the name given to the sensation of pain, burning or discomfort on the scalp, often described as "the roots of my hair hurt", frequently associated with phases of hair loss (telogen effluvium, pattern hair loss) and with stress or anxiety (Rebora et al., 1996). The skin looks normal. It is not dangerous, but it is uncomfortable and deserves an assessment of the cause of the hair loss.

Others

Tension headache and migraine can make the scalp tender to the touch. Seborrhoeic dermatitis, psoriasis and sunburn also cause discomfort.

What to do when a hairstyle hurts

At the time

• Let your hair down or take out the braids and extensions that hurt. Do not wait for it to "settle".
• Gently massage the scalp with your fingertips.
• Avoid heat and chemicals on the sore area.
• Do not use painkillers to be able to keep the hairstyle in. They relieve the pain, but not the traction that causes it.

In the following days

• Wear your hair loose or in wide, low hairstyles.
• Wash with a gentle shampoo and lukewarm water.
• Watch for spots, pus, crusts or hair falling out at the margins.

For the future

• Ask for braids and extensions that are wider, lighter and do not pull on the margins.
• Alternate the position of the ponytail and the parting.
• Use soft, metal-free hair ties and avoid tight clips.
• Respect the timings: braids two to three months at most; extensions six to eight weeks before a break.

See the complete guide in Braids and extensions without damaging your hair.

When to seek help

If you are over 50 and have these symptoms, contact SNS 24 (808 24 24 24), your doctor or go to an emergency department the same day. If you have a sudden, very severe headache, fever with a stiff neck, weakness, difficulty speaking or confusion, call 112.

Consultation in the next few days

• Pain, burning or tingling on one side only, with or without blisters.
• Spots, pus or crusts on the scalp.
• Reaction to extension glues or adhesives.

Hair Medicine consultation

• Persistent pain after giving up traction hairstyles.
• Thinner hair at the temples, front hairline or nape.
• Burning or discomfort on the scalp associated with hair loss (trichodynia).

At Luxmed, the Hair Medicine consultation assesses the scalp with trichoscopy, identifies signs of inflammation or traction and agrees with you a plan to ease the pain and protect the hair.

This article is for information only and does not replace a medical consultation. In case of urgent symptoms, call 112.

Frequently asked questions