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Headache: benign or worrisome? Keys to making the diagnosis.

Article Excerpt
Optimal treatment of headache requires accurate diagnosis. In most patients who seek treatment for headache from a primary care clinician, the cause is benign (primary headache).

More worrisome, however, both to the patient and the physician, is the secondary or organic headache, which may be associated with significant morbidity or even mortality. Headaches in this category include those of sudden onset in a person older than 50 years or younger than 5 years and those described as "the worst of my life." Other worrisome headache features are listed in Table 1.

The goal here is to help you rapidly rule out a serious underlying cause and then accurately identify the specific headache type.

TYPES OF BENIGN HEADACHE SEEN IN OFFICE PRACTICE

Benign headaches, such as migraines, are not caused by structural problems; however, they can interfere with the patient's lifestyle and functioning. Some headaches, such as tension-type headaches, are mild to moderate and are not exacerbated by routine physical activity. In fact, they usually respond to mild physical activity, or "a break from the routine." If not--or if the symptoms are exacerbated by activity--the diagnosis is usually migraine. Benign headaches may occasionally be associated with nausea or vomiting; anorexia may occur. Photophobia or phonophobia may also be present, as in migraine. Generally, the headache pattern remains stable over trine.

Although many more headache types are listed in the revised International Classification of Headache Disorders (ICHD II), (1) the primary care physician generally encounters only 9:

* Migraine without aura.

* Probable migraine without aura.

* Migraine with aura.

* Probable migraine with aura.

* Chronic migraine.

* Chronic migraine associated with analgesic overuse.

* Tension-type headache.

* Cluster headache.

* Chronic daily headache.

Table 2 lists the ICHD If diagnostic criteria for these headache types.

Patients who present with headache do so because the pain has become so severe or debilitating that it impairs their ability to function in occupational or social settings. Although tension-type headache is by far the most common type of headache--it occurs in about 70% of patients--it is rarely...

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