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A 27-year-old woman comes to your office to discuss her “sick headaches,” which started during high school. Her mother nudged her to see you. The headaches do not awaken her from sleep but can be disabling and occasionally require her to miss work. Sometimes she vomits during an attack. Over the past 6 months, her headaches have become more severe and frequent, prompting her visit today.

  • What additional questions would you ask to learn more about her headaches?
  • How do you classify headaches?
  • How can you determine if this is an old headache or a new headache?
  • Can you make a definite diagnosis through an open-ended history followed by focused questions?
  • How can you use the patient history to distinguish between benign headaches and serious ones that require urgent attention?

Headache is an exceedingly common symptom in primary care and other practice settings, ranking among the top 10 most frequent symptoms that prompt an office visit.1 Although most patients with headache will prove to have a benign cause, headache may occasionally herald a morbid or life-threatening diagnosis. A careful history will allow clinicians to establish the correct diagnosis in most cases, limit the use of unnecessary and expensive diagnostic testing, and lead to appropriate treatment to reduce suffering and disability. There are 2 general approaches to history taking for headache. The first is to learn the alarm features that should prompt consideration of a serious pathologic cause for headache. The second is to understand the typical features of common benign headache syndromes. This approach allows one to confidently diagnose migraine, tension-type, and cluster headaches based on the presence of characteristic historical features.

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Primary headacheA chronic, benign, recurring headache without known cause. Examples include migraine and tension-type headache.
Secondary headacheHeadache due to underlying pathology.
New headacheA headache of recent onset or a chronic headache that has changed in character. Such headaches are more likely to be pathologic than unchanged chronic headaches.
AuraComplex neurologic phenomena that precede a headache. Examples include scotoma, aphasia, and hemiparesis.
PhotophobiaPain or increased headache when looking into bright light.
PhonophobiaPain or increased headache with exposure to loud sounds.
Thunderclap headacheA headache that occurs instantaneously with maximal intensity at its onset.
Cervicogenic headacheReferred headache pain that originates from the neck, often due to muscle tension or cervical degenerative arthritis. Also referred to as occipital neuralgia.
Positive likelihood ratioThe increase in the odds of a diagnosis if a given clinical factor is present.
Negative likelihood ratioThe decrease in the odds of a diagnosis if a given clinical factor is absent.

Most chronic headaches are either migraines or tension-type headaches. The etiology of headache depends on the setting. Patients referred to specialized headache clinics have a disproportionately high frequency of medication-induced headache and chronic daily headache. In a study of unselected individuals in the general population, the ...

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