Primary headaches are the most common headache disorders. The most common forms are tension-type headaches, migraine, and cluster headache. Knowing the clinical presentation coupled with taking a thorough history taking and performing a thorough physical examination usually helps in arriving at a correct diagnosis. Special attention should be paid to unusual clinical presentations. Further diagnostic work-up should be performed in the presence of atypical and worrisome signs.
Key points
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Primary headache disorders are the most common forms of headaches.
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Taking a good history and performing thorough physical and neurologic examination are mandatory in evaluation of patients with headache.
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Unusual age of onset, sudden change in the headache pattern, headache deterioration, and lack of response to therapy, as well as presence of systemic symptoms such as fever and weight loss should warrant further diagnostic work-up.
Headaches are among the most frequent reasons for patients to seek medical attention and one of the largest contributors to disability. It is one of the most common disorders of nervous system. Primary headaches are the most common forms of headache disorders.
Primary headaches represent idiopathic pain conditions without underlying disorders, whereas secondary headaches disorders occur because of another pathologic process.
There are more than 17 different types of primary headache disorders with the most common being tension-type headache, migraines, and cluster headaches. Examples of secondary headache disorders are injury-related or trauma-related headaches, headaches secondary to infections, vascular disorders, and tumors ( Table 1 ).
| Primary Headache | Secondary Headache |
|---|---|
| Tension-type headache | Headache attributed to trauma or injury to the head or neck |
| Migraine | Headache attributed to cranial or cervical vascular disorder |
| Trigeminal autonomic cephalalgias | Headache attributed to a substance or its withdrawal |
| Primary exercise headaches | Headache attributed to infection |
| Primary stabbing headaches | Headache attributed to disorder or homeostasis |
| New daily persistent headache | Headache attributed to psychiatric disorder |
| Hypnic headache | Painful cranial neuropathies and other facial pains |
With some variations, primary headaches occur in all age groups, affecting people of different races and geographic locations as well as different income levels, thus representing a global problem. It has been reported that 47% of the general adult population worldwide experienced at least a single headache episode in the past year, whereas 1.7% to 4% of the adult population worldwide has been experienced chronic headaches (at least 15 headache days per month). According to the 2010 Global Burden of Disease Study, worldwide prevalence of tension-type headache was estimated to be 20% and migraine more than 14%, placing them in second and third places respectively among the most common disorders in the world. It has been estimated that migraine contributed to 2.9% of all years of life lost to disability, ranking it as number 7 among the most disabling disorders.
Tension-type headache
Tension-type headache is the most common primary headache disorder worldwide. Because tension-type headache is less severe and less disabling, it is seen less frequently in clinical practice. It has been estimated that 1-year prevalence of tension-type headache is 63% in men and 83% in women. Pathophysiology of tension-type headache is still poorly understood. A previously considered psychogenic cause does not reflect or explain all aspects of tension-type headache. It is currently thought that tension-type headaches have a strong neurobiological basis. At present, it is considered that peripheral pain mechanisms are involved in infrequent tension-type headache pathogenesis and central pain mechanisms in the chronic form. Presence of pericranial myofascial tenderness suggests the participation of central pain mechanisms, including possible sensitization at the level of dorsal horn and trigeminal nucleus caudalis. Because many patients with tension-type headache show symptoms of migraines (such as occasional presence of headache with a throbbing quality, and response to triptans), some specialist think that tension-type headache represents the opposite of the migraine end of the headache spectrum.
Tension-type headaches are subcategorized into 4 main categories: infrequent (less than 1 day per month), frequent (1–14 headache days per month for more than 3 month), chronic (more than 15 headache days per month for more than 3 months), and probable tension-type headache. The first 3 subcategories are also divided into tension-type headache associated with pericranial tenderness and those not associated with pericranial tenderness, which should be confirmed during physical examination ( Box 1 ).
- 2.
Tension-type headache
- 2.1.
Infrequent episodic tension-type headache
- 2.1.1.
Infrequent episodic tension-type headache associated with pericranial tenderness
- 2.1.2.
Infrequent episodic tension-type headache not associated with pericranial tenderness
- 2.1.1.
- 2.2.
Frequent episodic tension-type headache
- 2.2.1.
Frequent episodic tension-type headache associated with pericranial tenderness
- 2.2.2.
Frequent episodic tension-type headache not associated with pericranial tenderness
- 2.2.1.
- 2.3.
Chronic tension-type headache
- 2.3.1.
Chronic tension-type headache associated with pericranial tenderness
- 2.3.2.
Chronic tension-type headache not associated with pericranial tenderness
- 2.3.1.
- 2.4.
Probable tension-type headache
- 2.4.1.
Probable infrequent episodic tension-type headache
- 2.4.2.
Probable frequent episodic tension-type headache
- 2.4.3.
Probable chronic tension-type headache
- 2.4.1.
- 2.1.
Tension-type headache usually presents as mild to moderate, dull, pressurelike pain located in the forehead, in the occipital area. The pain is usually located bilaterally. Patients frequently describe tension-type headache as a rubber band–like sensation around the head. In more severe cases of tension-type headache, the pain has a throbbing or pulsating quality and may even be associated with either photophobia or phonophobia, which may represent a challenge in differentiating tension-type headache from a mild form of migraine without aura. Tension-type headache may last from 30 minutes to 7 days and usually is not aggravated by routine physical activity ( Box 2 ). Some patients obtain relief while participating in low-grade physical activity.
- A.
At least 10 episodes of headache occurring on fewer than 1 day per month on average (<12 days per year) and fulfilling criteria B to D
- B.
Lasting from 30 minutes to 7 days
- C.
At least 2 of the following 4 characteristics:
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Bilateral location
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Pressing or tightening (none pulsating) quality
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Mild or moderate intensity
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Not aggravated by routine physical activities such as walking or climbing stairs
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- D.
Both of the following:
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No nausea or vomiting
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No more than 1 of phonophobia or photophobia
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- E.
Not better accounted for by another International Classification of Headache Disorders, 3rd edition (ICDH-3) diagnosis
Case Presentation
A 42-year-old female advertising executive complains of intermittent headache. The pain is located bifrontally and she describes it as a pressure-like sensation. The headache is not associated with nausea or sensitivity to light or noise. She states that she is usually able to maintain her routine activities, although she feels fatigued most of the time. These headaches date back 5 years and have occurred weekly for the past 8 months. They frequently seem to be provoked by work-related stress. Physical examination revealed that the pericranial muscles were tender to palpation. The rest of the physical and neurologic examination, as well as results of blood work, were unremarkable.
The diagnosis was of frequent episodic tension-type headache associated with pericranial tenderness.
Clinical presentation of this case is typical for tension-type headache. Presence of systemic symptoms such as generalized fatigue should warrant further work-up. Differential diagnosis in this case should include hypothyroidism, anemia, fibromyalgia, and sinusitis. Absence of fever, nasal congestion especially with purulent discharge, and normal laboratory findings make diagnosis of sinusitis less likely. In addition, performing route blood work (including erythrocyte sedimentation rate, complete blood count, complete metabolic profile, and thyroid-stimulating hormone) should be helpful in making the correct diagnosis. Absence of chronic diffuse generalized myofascial pain makes diagnosis of fibromyalgia unlikely.
Tension-type headache
Tension-type headache is the most common primary headache disorder worldwide. Because tension-type headache is less severe and less disabling, it is seen less frequently in clinical practice. It has been estimated that 1-year prevalence of tension-type headache is 63% in men and 83% in women. Pathophysiology of tension-type headache is still poorly understood. A previously considered psychogenic cause does not reflect or explain all aspects of tension-type headache. It is currently thought that tension-type headaches have a strong neurobiological basis. At present, it is considered that peripheral pain mechanisms are involved in infrequent tension-type headache pathogenesis and central pain mechanisms in the chronic form. Presence of pericranial myofascial tenderness suggests the participation of central pain mechanisms, including possible sensitization at the level of dorsal horn and trigeminal nucleus caudalis. Because many patients with tension-type headache show symptoms of migraines (such as occasional presence of headache with a throbbing quality, and response to triptans), some specialist think that tension-type headache represents the opposite of the migraine end of the headache spectrum.
Tension-type headaches are subcategorized into 4 main categories: infrequent (less than 1 day per month), frequent (1–14 headache days per month for more than 3 month), chronic (more than 15 headache days per month for more than 3 months), and probable tension-type headache. The first 3 subcategories are also divided into tension-type headache associated with pericranial tenderness and those not associated with pericranial tenderness, which should be confirmed during physical examination ( Box 1 ).
- 2.
Tension-type headache
- 2.1.
Infrequent episodic tension-type headache
- 2.1.1.
Infrequent episodic tension-type headache associated with pericranial tenderness
- 2.1.2.
Infrequent episodic tension-type headache not associated with pericranial tenderness
- 2.1.1.
- 2.2.
Frequent episodic tension-type headache
- 2.2.1.
Frequent episodic tension-type headache associated with pericranial tenderness
- 2.2.2.
Frequent episodic tension-type headache not associated with pericranial tenderness
- 2.2.1.
- 2.3.
Chronic tension-type headache
- 2.3.1.
Chronic tension-type headache associated with pericranial tenderness
- 2.3.2.
Chronic tension-type headache not associated with pericranial tenderness
- 2.3.1.
- 2.4.
Probable tension-type headache
- 2.4.1.
Probable infrequent episodic tension-type headache
- 2.4.2.
Probable frequent episodic tension-type headache
- 2.4.3.
Probable chronic tension-type headache
- 2.4.1.
- 2.1.
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