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®.
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.
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
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
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.
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
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 ...