Key Points

• More than 90% of men and women will have at least one headache each year.

• If there is a history typical of a particular primary headache with a normal examination, neuroimaging and electroencephalography are not necessary.

• Prophylactic treatment of migraine headaches is recommended when they occur with increasing frequency and there appears to be a potential overuse of acute therapies.

• Giant cell or temporal arteritis is a serious headache to consider in older adults and can be associated with blindness.

Headaches are a common problem encountered by family physicians. More than 90% of men and women will have at least one headache each year, and as many as 4.5 million Americans will experience recurrent headaches. The International Headache Society established a system for the classification of headaches to assist in diagnosis and treatment with a standard of care for family physicians. Migraine with aura, migraine without aura, tension, and cluster headaches constitute most primary headaches. Secondary headaches are symptoms of organic disease (Sarchielli, 2004). The initial evaluation of a patient with headache requires a complete history and physical examination with the following information:

• Location, frequency, and duration

• Intensity and character

• Associated symptoms

• Triggering and ameliorating factors

• Medications

• Associated physical and neurologic symptoms

• Impact on work and family

• Psychological symptoms

• History of head trauma

• Previous imaging results

• Family history

Features of the history that should warn of an ominous cause for headache include the following: Sudden onset of first headache Worst headache ever

Late onset of new headache (after age 50 years) Headache associated with fever, rash, or stiff neck Progressively worsening headache

Headache associated with neurologic signs and symptoms other than aura

Headache associated with mental status changes Headache associated with papilledema Headache with exertion, sexual activity, coughing, or sneezing The physical examination of a patient first presenting for evaluation of headache should include vital signs, cardiac examination, cervical spine examination, including nuchal rigidity, and ophthalmologic examination, including the optic fundi, pupils, and visual fields. The neurologic examination should include an assessment of cognitive function, motor function, reflexes, plantar response, cranial nerves, coordination, and gait.

If there is a history typical of a particular primary headache with a normal examination, neuroimaging and electroen-cephalography (EEG) are not necessary. A lumbar puncture, after neuroimaging, is recommended only if there is suspicion of subarachnoid hemorrhage, infection, or idiopathic intracranial hypertension (pseudotumor cerebri). Routine EEG is not indicated but may be useful in evaluating patients with associated mental status or consciousness changes, a history of head injury, or a history of syncope.

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