Paul G. Mathew, M.D.,1,2 and Ivan Garza, M.D.3
KEYWORDS: Primary headache, migraine, trigeminal autonomic cephalgias, cluster headache, tension-type headache
EVALUATION The ﬁrst major step that a neurologist must take when evaluating a headache patient in an outpatient neurology practice is to establish whether the headache is a ‘‘primary’’ or ‘‘secondary’’ type ofheadache. Primary headaches are those that cannot be attributed to an underlying disorder, whereas secondary headaches are due to a speciﬁc underlying cause or disorder. In the case of secondary headaches, addressing the underlying disorder can often, but not always, lead to resolution of the headaches. Some of the common causes of secondary headaches are listed in Table 1.
History The mostfundamental and essential component in the evaluation of headaches is a thorough history. Table 2 summarizes the important elements of a headache hisDepartment of Neurology, Brigham and Womens Faulkner Hospital, John R. Graham Headache Center, Jamaica Plain, Massachusetts; 2 Division of Neurology, Cambridge Health Alliance, Cambridge, Massachusetts; 3Department of Neurology, Mayo Clinic, Rochester,Minnesota. Address for correspondence and reprint requests: Paul G. Mathew, M.D., John R. Graham Headache Center, 1153 Centre Street, Suite 4970, Jamaica Plain, MA 02130 (e-mail: PMATHEW@partners.org).
tory. The history should be chronological, and should document the evolution of all associated symptoms. It is vital to have the patient recall when the headaches began, and whether there were anytriggering events around the time of onset. Events such as head trauma, the presence of infectious diseases or inﬂammatory processes, and other neurologic disorders can all be associated with the development of headaches. Other details that should be elicited include the location, radiation, quality, frequency, and duration of pain. For female patients with headaches, seeking any prior or currentassociation with menstruation, pregnancy, and/ or hormone therapy can be useful. In addition, assessing the presence of photophobia, phonophobia, osmophobia, nausea, vomiting, cutaneous allodynia, unilateral runny/stuffy nose, monocular tearing, monocular eye redness, and unilateral eyelid ptosis can be helpful in classifying headaches. Patients
Ofﬁce-Based Neurology; Guest Editor, Devon I.Rubin, M.D. Semin Neurol 2011;31:5–17. Copyright # 2011 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. DOI: http://dx.doi.org/10.1055/s-0031-1271313. ISSN 0271-8235.
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Headache is one of the most common complaints among patients presenting to an outpatient neurologypractice. The evaluation, diagnosis, and treatment of headache can be rather cumbersome and at times quite challenging for even the most seasoned neurologist. Many complex issues that although not causative, can play an exacerbating role in the genesis of headaches. In this article, the authors review some of the essential elements that are part of headache evaluation including headache-speciﬁchistory, physical examination, warning signs of secondary headache disorders, and when to consider further studies. They then provide a brief review on the diagnosis of primary headache disorders according to the International Headache Society’s International Classiﬁcation of Headache Disorders, 2nd Edition (ICHD-2), and treatment strategies of the more common primary headache disorders with a focuson migraine, trigeminal autonomic cephalalgias, tension-type headache, and chronic daily headache.
SEMINARS IN NEUROLOGY/VOLUME 31, NUMBER 1
Table 1 Causes of Secondary Headache
Cause Cerebrovascular diseases Altered CSF dynamics Intracranial space-occupying lesion Infection Trauma Musculoskeletal Medications
CSF, cerebrospinal fluid.
Examples Carotid or vertebral...