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Am Fam Physician. 2022;106(3):260-268

This clinical content conforms to AAFP criteria for CME.

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 14 (Figure 1; Table 113 and Table 21,2,4).

RecommendationSponsoring 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 componentsExample questionsComment
Associated symptomsWhat 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
CharacterWhat 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 conditionsAre 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
DurationHow long does each attack last (e.g., seconds, minutes, hours, days)?Headaches lasting only seconds are unlikely to be tension-type headache or migraine
FrequencyHow 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
LocationWhere is the pain?
Is the headache unilateral or bilateral?
Does it radiate? To where?
Cluster headache and migraine tend to be unilateral
MedicationsWhat medications have you taken for the headache?
How often and at what dose?
Medication overuse can lead to headache
OnsetAt 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 factorsAre 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
SeverityHow 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 componentFeaturesComment
Vital signsBlood pressure, temperature, pulse, respirationsFever is a potential red flag
Focused neurologic examinationMental 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 disorderAssessment 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 infectionNeck examination to assess for meningeal irritationNote 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

Most patients who present for a headache evaluation have a primary headache disorder.6 The most diagnosed types of primary headaches are tension-type (46% to 78%), migraine (14% to 16%), and trigeminal autonomic cephalalgias (less than 1%1,7; Table 31,5,8).

Headache featuresTension-type headacheMigraine headacheTrigeminal autonomic cephalalgias and cluster headache
CharacteristicsNo 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 symptomsWith or without pericranial tendernessWith or without auraRestlessness or agitation
Duration30 minutes to 7 days4 to 72 hours15 minutes to < 3 hours
FrequencyAt least 10 attacks in a lifetimeAt least 5 attacks in a lifetimeAt 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 requirementSymptoms ≥ 15 days per month for > 3 monthsSymptoms ≥ 15 days per month for > 3 monthsRemission 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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