Physical and neurological examinations should be performed to exclude or confirm any secondary headache. The physical examination would generally produce normal findings in case of a primary headache. Attacks of cluster headache will produce physical findings including lacrimation, redness of the eyes, ptosis, and similar symptoms. In trigeminal neuralgia, pain trigger points can often be identified. Blood pressure and pulse should always be measured due to acute hypertension associated with headache. Computer tomography/magnetic resonance imaging (CT/MRI) scans are rarely indicative, but should be performed where the history or physical examination raise suspicion of a secondary condition.

Once a serious secondary headache has been excluded, the use of a headache diary for a minimum of 4 weeks and a headache calendar for a few months is highly recommended [5]. Two most frequently occurring types of migraine are migraine with aura and migraine without aura. Many patients have both types. Migraine without aura presents itself as attacks lasting from 4 to 72 h and the typical characteristics are throbbing unilateral headaches of moderate to severe intensity with aggravation by routine physical activity. These headaches are typically accompanied by nausea, vomiting, and phono- and/or photophobia (see Table 6.1). Patients are symptom-free between attacks. The lifetime prevalence of migraine is considered 16 %; this is based on the fulfillment of diagnostic criteria of five attacks of clear migraine without aura or two documented attacks of migraine with aura [2].

Various imaging studies have revealed not only changes in brain blood flow and metabolism but they are highly localized and related to the different symptoms during the attacks [8]. Recently, it has been shown that there are changes in the CNS during prodromal phase of an induced migraine attack [9] that provide more support to its origin in the CNS.

Approximately one-fourth of migraine patients have migraine with aura. The aura phase consists of lateralized, reversible symptoms from the vision and tactile senses, such as flickering scotomas and sensory disturbances [6].

Transitory aphasia may also occur. Typically, symptoms develop gradually over minutes, every aura symptom has duration of 5–60 min and several types of symptoms follow in a sequence (see Table 6.1). If aura includes motor weakness, the condition may be classified as hemiplegic migraine. In migraine with aura, the headache phase frequently meets the criteria for migraine without aura and is then classified as typical aura with migraine headache (see Table 6.1). It should be noted that aura is not necessarily followed by headache, and that such headache does not necessarily meet the criteria for migraine without aura. In these cases, the migraine is diagnosed as typical aura with non-migraine headache or as typical aura with no headache.

Warning signals that should attract physicians’ attention in particular and suggest in-depth examination are: