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A systematic search of the medical literature was performed in November 2004 and January 2007. The search, limited to human subjects and English language journals, included the National Guideline Clearinghouse, PubMed, and UpToDate®.

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Headache is one of the most common complaints encountered by health care practitioners. Headache may be symptomatic of a distinct pathologic process (secondary headache) or may occur without an underlying cause (primary headache). Most recurrent headaches are the result of a benign chronic headache disorder but headache may also be associated with a serious underlying medical condition.1 The primary headache disorders are migraine, tension-type, and cluster headache. The differential for secondary headache is quite long but may include infection, cerebral hemorrhage, or mass lesions. A complete headache history and physical examination are essential for accurate headache diagnosis. Primary care providers should be able to diagnose these conditions and provide appropriate therapeutic interventions. This chapter will focus on the diagnosis and management of the primary headache disorders.

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The presentation of migraine can vary and is usually divided into several phases (premonitory, aura, headache, and resolution). Premonitory symptoms are experienced by 20% to 60% of patients, usually a few hours or days before headache onset.2,3 Symptoms vary widely among migraine patients, but are generally consistent among individuals. Common neurologic symptoms include phonophobia, photophobia, hyperosmia, and difficulty in concentrating. Psychological symptoms include anxiety, depression, euphoria, irritability, drowsiness, hyperactivity, and restlessness. Constitutional symptoms include stiff neck, yawning, thirst, food cravings, and anorexia.4

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The migraine aura is a complex of positive and negative focal neurologic symptoms that precede, accompany, or, rarely, follow an attack. Aura is experienced by approximately 31% of migraine patients and is most often visual. Other aura symptoms include paresthesias involving the arms or face, dysphasia, or aphasia.2,4

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Migraines may occur at any time of the day or night but commonly occur early in the morning. The onset is gradual and the pain reaches a peak in a few minutes or hours. If left untreated, migraines typically last between 4 and 72 hours. The pain is most often unilateral, frontotemporal, and throbbing or pulsating. However, it, may be bilateral at onset or become generalized during the attack. Gastrointestinal symptoms are common and include nausea, emesis, anorexia, food cravings, constipation, diarrhea, and abdominal cramping.

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Presentation of tension-type headache differs from that of migraine in that premonitory symptoms and aura are absent. The pain is commonly bilateral and is described as a dull, nonpulsatile tightness or pressure. The classical description is that of pain having a “hatband” pattern. Associated symptoms are generally absent although mild photophobia and phonophobia may be reported.2,4

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Attacks of cluster headaches, as the name suggests, occur in cluster periods, lasting from 2 weeks to 3 months in most patients, followed by pain-free or remission intervals. They occur most often at ...

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