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Evaluation of headache in adults

Zahid H Bajwa, MD
R Joshua Wootton, MDiv, PhD
Section Editor
Jerry W Swanson, MD, MHPE
Deputy Editors
John F Dashe, MD, PhD
Susanna I Lee, MD, PhD


Headache is among the most common medical complaints. An overview of the approach to the patient with headache is presented here. The approach to adults presenting with headache in the emergency department is reviewed elsewhere. (See "Evaluation of the adult with headache in the emergency department".)

The clinical features and management of specific primary headache syndromes are discussed separately. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults" and "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis" and "Cluster headache: Epidemiology, clinical features, and diagnosis".)


As many as 90 percent of all benign headaches fall under a few categories, including migraine, tension-type, cluster, and chronic daily headache. While episodic tension-type headache is the most frequent headache type in population-based studies, migraine is the most common diagnosis in patients presenting to primary care physicians with headache. The one-year prevalence of episodic tension-type headache (TTH) is approximately 65 percent (see "Tension-type headache in adults: Pathophysiology, clinical features, and diagnosis", section on 'Epidemiology'), but most people with tension-type headache do not present to physicians for care. As an example, a study of two primary care units in Brazil found that migraine was the most prevalent primary headache disorder, accounting for 45 percent of patients reporting headache as a single symptom [1].

Cluster headache typically leads to significant disability and most of these patients will come to medical attention. However, cluster headache remains an uncommon diagnosis in primary care settings because of overall low prevalence in the general population (<1 percent). (See "Cluster headache: Epidemiology, clinical features, and diagnosis", section on 'Epidemiology'.)

Clinicians can easily become familiar with the most common primary headache disorders and how to distinguish them (table 1).

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Literature review current through: Nov 2017. | This topic last updated: Dec 20, 2016.
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  1. Bigal ME, Bordini CA, Speciali JG. Etiology and distribution of headaches in two Brazilian primary care units. Headache 2000; 40:241.
  2. Cady RK, Schreiber CP. Sinus headache or migraine? Considerations in making a differential diagnosis. Neurology 2002; 58:S10.
  3. Mehle ME. What do we know about rhinogenic headache? The otolaryngologist’s challenge. Otolaryngol Clin North Am 2014; 47:255.
  4. Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Study (SAMS). Headache 2007; 47:213.
  5. Gil-Gouveia R, Martins IP. Headaches associated with refractive errors: myth or reality? Headache 2002; 42:256.
  6. Buring JE, Hebert P, Romero J, et al. Migraine and subsequent risk of stroke in the Physicians' Health Study. Arch Neurol 1995; 52:129.
  7. Hagen K, Stovner LJ, Vatten L, et al. Blood pressure and risk of headache: a prospective study of 22 685 adults in Norway. J Neurol Neurosurg Psychiatry 2002; 72:463.
  8. Edmeads J. Emergency management of headache. Headache 1988; 28:675.
  9. Lipton RB, Bigal ME, Steiner TJ, et al. Classification of primary headaches. Neurology 2004; 63:427.
  10. Lynch KM, Brett F. Headaches that kill: a retrospective study of incidence, etiology and clinical features in cases of sudden death. Cephalalgia 2012; 32:972.
  11. Dodick D. Headache as a symptom of ominous disease. What are the warning signals? Postgrad Med 1997; 101:46.
  12. Venkatesan A. Case 13: a man with progressive headache and confusion. MedGenMed 2006; 8:19.
  13. Shindler KS, Sankar PS, Volpe NJ, Piltz-Seymour JR. Intermittent headaches as the presenting sign of subacute angle-closure glaucoma. Neurology 2005; 65:757.
  14. Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001; 41:638.
  15. Barbanti P, Fabbrini G, Pesare M, et al. Unilateral cranial autonomic symptoms in migraine. Cephalalgia 2002; 22:256.
  16. Cady RK, Schreiber CP. Sinus headache: a clinical conundrum. Otolaryngol Clin North Am 2004; 37:267.
  17. Rapoport AM, Bigal ME. ID-migraine. Neurol Sci 2004; 25 Suppl 3:S258.
  18. Cousins G, Hijazze S, Van de Laar FA, Fahey T. Diagnostic accuracy of the ID Migraine: a systematic review and meta-analysis. Headache 2011; 51:1140.
  19. Maizels M, Burchette R. Rapid and sensitive paradigm for screening patients with headache in primary care settings. Headache 2003; 43:441.
  20. Kumar KL, Cooney TG. Headaches. Med Clin North Am 1995; 79:261.
  21. Goadsby PJ. To scan or not to scan in headache. BMJ 2004; 329:469.
  22. Tsushima Y, Endo K. MR imaging in the evaluation of chronic or recurrent headache. Radiology 2005; 235:575.
  23. You JJ, Gladstone J, Symons S, et al. Patterns of care and outcomes after computed tomography scans for headache. Am J Med 2011; 124:58.
  24. Dumas MD, Pexman JH, Kreeft JH. Computed tomography evaluation of patients with chronic headache. CMAJ 1994; 151:1447.
  25. Silberstein SD, Rosenberg J. Multispecialty consensus on diagnosis and treatment of headache. Neurology 2000; 54:1553.
  26. Hale N, Paauw DS. Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and new considerations in diagnosis and management. Med Clin North Am 2014; 98:505.
  27. Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: A narrative review. Cephalalgia 2015; 35:894.
  28. Schreiber CP, Hutchinson S, Webster CJ, et al. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. Arch Intern Med 2004; 164:1769.
  29. Cady RK, Dodick DW, Levine HL, et al. Sinus headache: a neurology, otolaryngology, allergy, and primary care consensus on diagnosis and treatment. Mayo Clin Proc 2005; 80:908.
  30. Tarabichi M. Characteristics of sinus-related pain. Otolaryngol Head Neck Surg 2000; 122:842.
  31. Levine HL, Setzen M, Cady RK, et al. An otolaryngology, neurology, allergy, and primary care consensus on diagnosis and treatment of sinus headache. Otolaryngol Head Neck Surg 2006; 134:516.
  32. Marmura MJ, Silberstein SD. Headaches caused by nasal and paranasal sinus disease. Neurol Clin 2014; 32:507.