Headache is one of the most common presenting complaints in outpatient practice. Although most are primary headaches, especially migraine and tension headache, a small percentage result from a more serious underlying secondary cause.


Patients who have headaches secondary to a serious underlying cause usually have distinct historical or exam findings such as underlying systemic disease; new or different pattern from previous headaches or new headaches in patients over age 50; focal neurologic symptoms or seizures; symptoms provoked by standing, lying down, valsalva, cough, or sexual activity; history of neoplasia, immunosuppression, or HIV; systemic signs or symptoms; sudden onset symptoms; or papilledema. Any of these findings indicates the need for aggressive workup.1


Even though tension headache is more common, most of the disability we see in the office is from migraine. Eighteen percent of women and 6% of men have migraine. Characteristics that suggest migraine are headaches lasting 4 to 72 hours, unilateral pain, throbbing pain, pain worse with exercise, moderate to severe pain, associated nausea, vomiting, and light and sound sensitivity (Table 1). Thirty percent of patients with migraine have an aura that occurs before or at the onset of the headache and is most often visual but may be sensory, linguistic, or motor.2

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TABLE 1. Migrane diagnostic criteria

One from Group A:
Group A
  • Unilateral
  • Moderate to severe
  • Worse with exercise
  • Throbbing in character
One from Group B:
Group B
  • Nausea OR vomiting
  • Light AND sound sensitivity