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  • Migraine.

    • Headache lasting 4–72 hours.

    • Unilateral onset often spreading bilaterally.

    • Pulsating quality and moderate or severe intensity of pain.

    • Aggravated by or inhibiting physical activity.

    • Nausea and photophobia.

    • May present with an aura.

  • 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.

  • Tension-type headache.

    • Pressing or tightening (nonpulsating) pain.

    • Bilateral bandlike distribution of pain.

    • Not aggravated by routine physical activity.


Headache is among the most common pain syndromes presenting in primary care with a lifetime prevalence of >90% among adults. Population-based studies of US adults reveal that the prevalence of migraine and probable migraine is approximately 16%, with a female-to-male ratio of approximately 3:1. The prevalence among both genders is 31.2–38.3% for episodic and 2.2% for chronic tension-type headache. The main task before the primary care provider is to determine whether 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. These disorders include migraine (with and without aura), tension-type headache, and cluster headache. Secondary headache disorders constitute 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. The International Headache Society provides a detailed classification of primary and secondary headache disorders on their website

Green  MW. Secondary headaches. Continuum. 2012;18(4):783–795. [22868541]
Kaniecki  RG. Tension-type headache. Continuum. 2012;18(4):823–834.
[PubMed: 22868544]
Sahler  K. Epidemiology and cultural differences in tension-type headache. Curr Pain Headache Rep. 2012;16:525–532.
[PubMed: 22948318]
Smitherman  TA  et al.. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache. 2013;53(3):427–436.
[PubMed: 23470015]


A. Symptoms and Signs

1. History

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 29-1). 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 29-2).

Table 29–1.Questions to ask when obtaining a headache history.

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