Am Fam Physician. 2022;106(3):260-268
Author disclosure: No relevant financial relationships.
A detailed history and physical examination can distinguish between key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache. Most headaches that are diagnosed in the primary care setting are benign. Among primary headache disorders, tension-type headache is the most common, although a migraine headache is more debilitating and likely to present in the primary care setting. Signs such as predictable timing, sensitivity to smells or sounds, family history of migraine, recurrent sinus headache, or recurrent severe headaches with a normal neurologic examination could indicate migraine headache. Evaluating acute headaches using a systematic framework such as the SNNOOP10 mnemonic can help detect life-threatening secondary causes of headaches. Red flag signs or symptoms such as acute thunderclap headache, fever, meningeal irritation on physical examination, papilledema with focal neurologic signs, impaired consciousness, and concern for acute glaucoma warrant immediate evaluation. For emergent evaluations, noncontrast computed tomography of the head is recommended to exclude acute intracranial hemorrhage or mass effect. A lumbar puncture is also needed to rule out subarachnoid hemorrhage if the scan result is normal. For less urgent cases, magnetic resonance imaging of the brain is preferred for evaluating headaches with concerning features. Primary headache disorders without red flags or abnormal examination findings do not need neuroimaging.
A detailed history and physical examination can distinguish between key features of benign primary headaches (e.g., tension-type, migraine, trigeminal autonomic cephalalgia) and concerning symptoms that warrant further evaluation for a secondary headache (e.g., subarachnoid hemorrhage, giant cell arteritis). Most headaches assessed in primary care are benign. It is important to diagnose a patient's headache accurately and identify patients for whom an additional but less urgent evaluation is necessary 1–4 (Figure 1; Table 11–3 and Table 21,2,4).
| Recommendation | Sponsoring organization |
|---|---|
| Do not perform imaging for uncomplicated headache. | American College of Radiology |
| Do not perform neuroimaging studies in patients with stable headaches that meet criteria for migraine. | American Headache Society |
| Do not perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings. | American Headache Society |
| Do not perform electroencephalography for headaches. | American Academy of Neurology |
| History components | Example questions | Comment |
|---|---|---|
| Associated symptoms | What are your associated symptoms (e.g., aura, nausea, vomiting, photophobia, autonomic symptoms, neck pain, fever)? | Noting an aura before a headache suggests migraine; neck pain and fever are potential red flags |
| Character | What are the headache qualities (e.g., pulsatile, throbbing, pressure-like)? Has the headache changed in intensity or frequency? | Changes in quality, frequency, or intensity should merit further evaluation |
| Comorbid conditions | Are there other medical problems that may be related to headache (e.g., mood symptoms, hypertension, pregnancy, history of heart disease or stroke, immunosuppression)? | Comorbidities may need to be factored into the diagnosis and management plan |
| Duration | How long does each attack last (e.g., seconds, minutes, hours, days)? | Headaches lasting only seconds are unlikely to be tension-type headache or migraine |
| Frequency | How often do the attacks occur (e.g., days per month)? How many days per week or month are you headache-free? | Helps distinguish between acute and chronic headache |
| Location | Where is the pain? Is the headache unilateral or bilateral? Does it radiate? To where? | Cluster headache and migraine tend to be unilateral |
| Medications | What medications have you taken for the headache? How often and at what dose? | Medication overuse can lead to headache |
| Onset | At what age did the headaches begin? Was the onset sudden or gradual? | Sudden onset and onset at 50 years and older are more concerning |
| Precipitating factors | Are there symptoms before the headache starts (e.g., aura, jaw pain), activities (e.g., trauma, cough, exertion, sexual intercourse, neck movement), or ingestions (e.g., alcohol, tobacco, caffeine) that trigger the headache? Are headaches predictable in timing (e.g., before menstruation or ovulation)? | Migraine may have predictable triggers |
| Severity | How quickly does the headache peak in intensity? How bad is the pain on a scale of 1 to 10? How does the headache affect your daily functioning? | Tension-type headache tends to develop insidiously; migraine is more sudden |
| Examination component | Features | Comment |
|---|---|---|
| Vital signs | Blood pressure, temperature, pulse, respirations | Fever is a potential red flag |
| Focused neurologic examination | Mental status, Glasgow Coma Scale score Cranial nerve evaluation including funduscopy Strength and sensory tests Deep tendon reflexes Coordination and gait | Any abnormal neurologic examination finding is a red flag |
| Concern for temporomandibular joint disorder | Assessment of jaw opening Palpation of mastication muscles (masseter, temporalis, pterygoids) | Decreased range of motion or tenderness with palpation is concerning |
| Concern for central nervous system infection | Neck examination to assess for meningeal irritation | Note that classic features such as Kernig sign and Brudzinski sign are of limited value |
Headache Classification
The International Classification of Headache Disorders publishes an extensive classification system5; however, a simpler approach is to categorize headaches into primary and secondary disorders. Primary headache disorders are benign and do not have a separate underlying etiology that requires further evaluation. Some secondary headache disorders can be life-threatening and are caused by an underlying process such as medication overuse, infection, head trauma, or subarachnoid hemorrhage.
Primary Headache Disorders
| Headache features | Tension-type headache | Migraine headache | Trigeminal autonomic cephalalgias and cluster headache |
|---|---|---|---|
| Characteristics | No nausea and 2 or more of the following: Bilateral location Nonpulsatile pain (usually pressing, tightening) Mild to moderate intensity Not exacerbated by activity | At least 1 of the following: Nausea or vomiting Photophobia or phonophobia And 2 or more of the following: Unilateral location Pulsatile pain Moderate to severe intensity Exacerbated with activity | Unilateral (usually recurs on the same side) Severe orbital, supraorbital, or temporal pain And 1 or more of the following ipsilateral features: Conjunctival erythema or lacrimation Rhinorrhea Forehead or facial diaphoresis Upper eyelid ptosis or constricted pupil |
| Other symptoms | With or without pericranial tenderness | With or without aura | Restlessness or agitation |
| Duration | 30 minutes to 7 days | 4 to 72 hours | 15 minutes to < 3 hours |
| Frequency | At least 10 attacks in a lifetime | At least 5 attacks in a lifetime | At least 5 attacks in a lifetime Each cluster attack occurs from every other day to 8 per day Cluster attacks cycle between remission periods of a few months |
| Chronic type diagnosis requirement | Symptoms ≥ 15 days per month for > 3 months | Symptoms ≥ 15 days per month for > 3 months | Remission interval < 3 months, or attacks occur for ≥ 1 year without remission |
TENSION-TYPE HEADACHE
Tension-type headache (TTH) is the most common primary headache disorder but may not be addressed in the clinical setting because it is not typically disabling unless chronic. One study estimated a lifetime prevalence as high as 78%, and another found that in any year, 38% of adults in the United States have TTH disorder.9,10 Prevalence peaks between 30 and 39 years of age, and TTH occurs slightly more often in women.10
Classically, TTH causes a bilateral, nonpulsatile pain attack of mild to moderate intensity. TTH subtypes are stratified based on frequency: infrequent episodic (less than one day per month), frequent episodic (one to 14 days per month), and chronic (15 or more days per month).5 The diagnosis of episodic TTH is more common than chronic. Patients with chronic TTH have a greater burden of disease. One study reported a threefold increase in average days missed from work for patients diagnosed with chronic vs. episodic TTH (27 vs. nine days per year).10
MIGRAINE HEADACHE
Migraine headache has a lifetime prevalence of 16% and a one-year prevalence of 12%.11,12 Migraine headache is more common in women (one-year prevalence is 17% of women vs. 5.6% of men).12 Migraine prevalence peaks between 20 and 50 years of age. Although an acute headache is the fourth most common reason for an emergency department visit, nearly 53% of visits for migraine headaches in the United States occur in primary care settings.13
Although migraine headache is less common than TTH, it is more debilitating. One study concluded that migraine headache significantly reduced quality of life to a similar degree as congestive heart failure, hypertension, or diabetes mellitus.14 The annual direct and indirect cost of health care resources and lost productivity was estimated to be $36 billion in 2016, likely driven by the high prevalence of migraine headache during peak employment years.15
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