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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/or photophobia and phonophobia.

    • 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 band-like distribution of pain.

    • Not aggravated by routine physical activity.


Headache is among the most common pain syndromes, consistently ranking as the fourth or fifth leading reason to present to an emergency department (ED) and accounting for approximately 3% of all ED visits. Population-based studies reveal that approximately 15% of all US adults report having had a migraine or severe headache in the last 3 months, with a female-to-male ratio of approximately 2.4:1. Regarding tension-type headache, the prevalence among both genders is 31.2–38.3% for episodic and 2.2% for chronic tension-type headache. Cluster headache has a prevalence of about 0.1% of the US population, with a male-to-female ratio of approximately 3:1. Although headache disorders such as migraine, tension-type, and cluster headaches are most frequently encountered, 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 (ie, benign, recurrent headaches having no organic disease as their cause) and secondary headaches (ie, 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 (

Burch  R, Rizzoli  P, Loder  E. The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Headache. 2018;58(4):496–505.
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Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38:1–211.
[PubMed: 29368949]
Hoffmann  J, May  A. Diagnosis, pathophysiology, and management of cluster headache. Lancet Neurol. 2018;17:75–83.
[PubMed: 29174963]  
Kaniecki  RG. Tension-type headache. Continuum. 2012;18:823–834.
[PubMed: 22868544]  


A. Symptoms and Signs

1. History

The majority of patients presenting with headache have a normal neurologic and general physical examination; ...

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