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After studying this chapter, the student should be able to:

  • Recognize and indicate treatment for the main primary headache disorders, including migraine with and without aura, tension-type headache, and trigeminal autonomic cephalgias.

  • Recognize and indicate treatment for the main secondary headache disorders, including medication overuse headache, medication/caffeine withdrawal headache, idiopathic intracranial hypertension (pseudotumor cerebri), and spontaneous intracranial hypotension.

  • Recognize the diagnostic “red flags” that warrant imaging and further workup.

  • Identify the major neurologic pain syndromes, including fibromyalgia, complex regional pain syndrome, postherpetic neuralgia, trigeminal neuralgia, phantom limb pain, and central pain syndrome.


Headache is perhaps the most common neurologic syndrome. About half the world’s population experiences headache at least once each year, and up to three-quarters of people will have a headache at some point in their lives. The most common type of headache is tension-type headache, followed by migraine. The 1-year prevalence of migraine in the United States is 12%, with a female predominance. Migraine prevalence is highest during some of the peak productive years of life (age 30 to 39 years), and 1 of every 4 migraineurs misses at least 1 day of work every 3 months. Migraine is among the top 10 causes of disability worldwide and accounts for the most years lived with disability of any neurologic disorder.


The workup of a headache is guided by several factors in the history and exam (Figure 26–1). The more common primary headache disorders, namely migraine and tension-type headache, are diagnosed based on a thorough history and physical exam. Neuroimaging is not required unless the patient has an abnormal neurologic exam or the history is concerning. However, secondary headaches could masquerade as trigeminal autonomic cephalgias and some of the headaches classified under other primary headache disorders; therefore, further workup is often warranted. There are a number of potential “red flags” in the history that may suggest the need for further workup (Table 26–1).


Headache algorithm. It is important to understand new-onset versus chronic headache and then tease out warning signs for potential secondary headache from a patient’s history and physical exam. CNS, central nervous system; GCA, giant-cell arteritis; TMJ, temporomandibular joint. (Reproduced with permission from Henderson MC, Tierney LM, Smetana GW: The Patient History: Evidence-Based Approach to Differential Diagnosis. 2nd ed. New York, NY: McGraw Hill; 2012.)

TABLE 26–1Warning signs in the history that raise concern.

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