Table 5.

Diagnosing primary headache syndromes

DESCRIPTIONHEADACHE SYNDROME
Patients with recurrent headache attacks and normal neurologic examination findings (in some patients other clinical symptoms might also need to be considered)*

  • Diagnose migraine without aura (migraine with aura if an aura is present) if they have at least 2 of the following:

    • -nausea during the attack

    • -light sensitivity during the attack

    • -some of the attacks interfere with their activities

  • Diagnose episodic tension-type headache† if headache attacks are not associated with nausea, and have at least 2 of the following:

    • -bilateral headache

    • -nonpulsating pain

    • -mild to moderate intensity

    • -headache is not worsened by activity

  • Diagnose cluster headache or another trigeminal autonomic cephalalgia if headache attacks meet all the following criteria:

    • -frequent

    • -severe

    • -brief (duration < 3 h)

    • -unilateral

    • -ipsilateral conjunctival injection, tearing, or restlessness during the attacks (ipsilateral ptosis or miosis might be present on examination). Neurologist referral recommended

Patients with headache on ≥ 15 d/mo for > 3 mo and with normal neurologic examination findings‡

  • Diagnose chronic migraine if headaches meet migraine diagnostic criteria (above) or are quickly aborted by migraine-specific medications (triptans or ergots) on ≥ 8 d/mo

    • -Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on ≥ 10 d/mo or uses plain acetaminophen or NSAIDs on ≥ 15 d/mo

    • -Chronic migraine without medication overuse if patients do not have medication overuse as defined above

  • Diagnose chronic tension-type headache if headaches meet episodic tension-type headache diagnostic criteria (above), except mild nausea might be present

Patients with continuous daily headache for > 3 mo with normal neurologic examination findings§

  • Diagnose hemicrania continua‖ (neurologist referral recommended) if the headache

    • -is strictly unilateral

    • -is always on the same side of the head (ptosis or miosis might be present on examination)

    • -responds dramatically to indomethacin

  • Diagnose new daily persistent headache‖ if the headache is unremitting since its onset. It is important to consider secondary headaches in these patients. Neurologist referral recommended

  • NSAID—nonsteroidal anti-inflammatory drug.

  • ↵* Modified from the International Classification of Headache Disorders32; data from Lipton et al33; and based on expert opinion of the Guideline Development Group.

  • ↵† If patients do not meet migraine diagnostic criteria.

  • ↵‡ Modified from the International Classification of Headache Disorders32 and based on expert opinion of the Guideline Development Group.

  • ↵§ Modified from the International Classification of Headache Disorders32 and based on expert opinion of the Guideline Development Group.

  • ↵‖ This less common headache syndrome should be considered in patients with continuous headache.