Essentials of Diagnosis
- Migraine.
- Headache lasting 4-72 hours.
- Unilateral onset often spreading bilaterally.
- Pulsating quality and moderate or severe intensityof pain.
- Aggravated by or inhibiting physical activity.
- Nausea and photophobia.
- May present with an aura.
- Headache lasting 4-72 hours.
- Cluster headache.
- Strictly unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes.
- Explosive excruciating pain.
- One attack every other day to eight attacks per day.
- Strictly unilateral orbital, supraorbital, or temporal pain lasting 15-180 minutes.
- Tension-type headache.
- Pressing or tightening (nonpulsating) pain.
- Bilateral band-like distribution of pain.
- Not aggravated by routine physical activity.
- Pressing or tightening (nonpulsating) pain.
Headache is among the most common pain syndromes presenting in primary care with a lifetime prevalence of over 90% among adults. The prevalence of migraine is approximately 18% in women and 6% in men; the prevalence among both genders is 38.3% for episodic and 2.2% for chronic tension-type headache. The main task before the primary care provider is to determine if the patient has a potentially life-threatening headache disorder and, if not, to provide appropriate management to limit disability from headache.
A distinction between primary headaches (benign, recurrent headaches having no organic disease as their cause) and secondary headaches (those caused by an underlying, organic disease) is practical in primary care. Over 90% of patients presenting to primary care providers have a primary headache disorder (Table 28-1). These disorders include migraine (with and without aura), tension-type headache, and cluster headache. Secondary headache disorders comprise the minority of presentations; however, given that their underlying etiology may range from sinusitis to subarachnoid hemorrhage, these headache disorders often present the greatest diagnostic challenge to the practicing clinician (Table 28-2).
| Migraine |
| Migraine without aura |
| Migraine with aura |
| Childhood periodic syndromes that are commonly precursors of migraine |
| Retinal migraine |
| Complications of migraine |
| Probable migraine |
| Tension-type headache (TTH) |
| Infrequent episodic TTH |
| Frequent episodic TTH |
| Chronic TTH |
| Probable TTH |
| Cluster headache and other trigeminal autonomic cephalalgias |
| Cluster headache |
| Paroxysmal hemicrania |
| Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) |
| Probable trigeminal autonomic cephalalgia |
| Other primary headaches |
| Primary stabbing headache |
| Primary cough headache |
| Primary exertional headache |
| Primary headache associated with sexual activity |
| Hypnic headache |
| Primary thunderclap headache |
| Hemicrania continua |
| New daily-persistent headache (NDPH) |
| Headache attributed to head or neck trauma |
| Acute post-traumatic headache |
| Chronic post-traumatic headache |
| Acute headache attributed to whiplash injury |
| Chronic headache attributed to whiplash injury |
| Headache attributed to cranial or cervical vascular disorder |
| Headache attributed to subarachnoid hemorrhage |
| Headache attributed to giant cell arteritis |
| Headache attributed to nonvascular intracranial disorder |
| Headache attributed to idiopathic intracranial hypertension |
| Postdural puncture headache |
| Headache attributed to increased intracranial pressure or hydrocephalus caused by neoplasm |
| Headache attributed directly to neoplasm |
| Postseizure headache |
| Headache attributed to a substance or its withdrawal |
| Carbon monoxide-induced headache |
| Medication-overuse headache |
| Headache attributed to infection |
| Headache attributed to intracranial infection |
| Headache attributed to bacterial meningitis |
| Chronic post-bacterial meningitis headache |
| Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures |
| Headache attributed to psychiatric disorder |
| Cranial neuralgias and central causes of facial pain |
| Trigeminal neuralgia |
| Occipital neuralgia |
| Postherpetic neuralgia |
| Ophthalmoplegic “migraine” |
| Other headache, cranial neuralgia, central or primary facial pain |
The majority of patients presenting with headache have a normal neurologic and general physical examination; for this reason, the headache history is of utmost importance (Table 28-3). A key issue in the headache history is identifying patients presenting with “red flags”diagnostic alarms that prompt greater concern for the presence of a secondary headache disorder and a greater potential need for additional laboratory evaluation and neuroimaging (Table 28-4).
| H: | How severe is your headache on a scale of 1-10 (1 = minimal pain, 10 = severe pain)? How did this headache start (gradually, suddenly, other)? How long have you had this headache? |
| E: | Ever had headaches before? Ever had a headache this bad before (first or worst headache)? Ever have headaches just like this one in the past? |
| A: | Any other symptoms noted before or during your headache? Any symptoms right now? |
| D: | Describe the quality of your pain (throbbing, stabbing, dull, other). Describe the location of your pain. Describe where your pain radiates. Describe any other medical problems you may have. Describe your use of medications (prescription and over- the-counter products). Describe any history of recent trauma or any medical or dental procedures. |
| Red Flag | Differential Diagnosis | Possible Workup |
|---|---|---|
| Headache beginning after 50 y of age | Temporal arteritis, mass lesion | Erythrocyte sedimentation rate, neuroimaging |
| Very sudden onset of headache | Subarachnoid hemorrhage, pituitary apoplexy, hemorrhage into a mass lesion or vascular malformation, mass lesion (especially posterior fossa mass) | Neuroimaging, lumbar puncture if computed tomography is negative |
| Headaches increasing in frequency and severity | Mass lesion, subdural hematoma, medication overuse | Neuroimaging, drug screen |
| New-onset headache in patient with risk factors for HIV infection or cancer | Meningitis (chronic or carcinomatous), brain abscess (including toxoplasmosis), metastasis | Neuroimaging, lumbar puncture if neuroimaging is negative |
| Headache with signs of systemic illness (eg, fever, still neck, rash) |
