Diagnosing Secondary and Primary Headache Disorders

PURPOSE OF REVIEW This article provides a systematic diagnostic approach to the patient with headache.

RECENT FINDINGS The vast majority of patients presenting with headache in clinical practice have a primary headache disorder. The most common primary headache disorder in clinical practice is overwhelmingly migraine. Unfortunately, a substantial proportion of patients with migraine do not receive an accurate diagnosis. In addition, the clinical features of migraine overlap with secondary causes of headache, making a careful history and deliberative evaluation for warning symptoms or signs of a secondary headache disorder of paramount importance.

SUMMARY The approach to the patient with headache requires knowledge of the diagnostic criteria for primary headache disorders, recognition of the importance of a systematic evaluation for red flags associated with secondary headache disorders, and awareness of the pearls and pitfalls encountered in the diagnostic evaluation of a patient with headache.

Address correspondence to Dr David W. Dodick, Mayo Clinic, 13400 E Shea Blvd, Scottsdale AZ 85259, [email protected].

RELATIONSHIP DISCLOSURE: Dr Dodick has served as a consultant for AEON Biopharma; Alder Biopharmaceuticals Inc; Allergan; Amgen Inc; Atria BPH; Biohaven Pharmaceuticals; Cerecin Inc; Clexio Biosciences; Cooltech Medical; Ctrl M Health; eNeura Inc; Equinox Pharma Limited; GlaxoSmithKline plc; Impel NeuroPharma, Inc; Lilly; Linpharma, Inc; Lundbeck; Nocira; Novartis AG; Pieris Pharmaceuticals; Praxis Pharmaceutical; Promius Pharma, LLC; Revance; Satsuma Pharmaceuticals, Inc; Theranica Bio-Electronics Ltd; Upjohn (Division of Pfizer Inc); W. L. Gore & Associates, Inc; Xoc Pharmaceuticals, Inc; and Zosano Pharma Corporation, as chair of the American Brain Foundation, and on the board of directors of the American Migraine Foundation; EPIEN Medical, Inc; King-Devick Technologies, Inc; Matterhorn Medical Ltd; Ontologics, Inc; and Precon Health Inc. Dr Dodick has received personal compensation for speaking engagements from Academy for Continued Healthcare Learning; Cambridge University Press; Clinical Care Solutions; CME Outfitters; Curry Rockefeller Group; DeepBench; Global Access Meetings, Inc; KLJ Associates; Majallin LLC; MedLogix Communications; MJH Life Sciences; Miller Medical Communications, LLC; Oxford University Press; Southern Headache Society (Mountain Area Health Education Center); WebMD LLC/Medscape; and Wolters Kluwer, NV. Dr Dodick holds stock or stock options in Aural Analytics; Ctrl M Health; EPIEN Medical, Inc; ExSano Inc; Healint Pte Ltd; King-Devick Technologies, Inc; Matterhorn Medical Ltd; Nocira; Ontologics, Inc; Palion Medical; Precon Health Inc; Second Opinion/Mobile Health, and Theranica Bio-Electronics Ltd. Dr Dodick receives research/grant support from the American Migraine Foundation, the Henry M. Jackson Foundation for the Advancement of Military Medicine, the National Institutes of Health (R21 HD089035, U01 NS093334), the Patient-Centered Outcomes Research Institute, the Sperling Foundation, and the US Department of Defense (FP00114103) and patent royalties for a botulinum toxin dosage regimen for chronic migraine prophylaxis.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Dodick reports no disclosure.