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Headache is one of the most common painful conditions for which patients consult physicians. Surveys indicate that in any given year, more than 90% of American adults will suffer some kind of headache or head pain.1 Fortunately, very few headaches are caused by serious organic conditions, and most headaches are actually migraine or tension-type headache. The first step in treating a patient with headache is to establish an accurate diagnosis, and for diagnostic purposes headaches are divided into primary and secondary headache disorders. Secondary headaches have an underlying cause, such as infection, eye disease, tumor, aneurysm, meningitis, and so forth. Primary headache disorders are benign and tend to recur. These headaches are caused by conditions for which the true basis has not yet been established, but altered brain serotonin chemistry clearly plays a role (see Chapter 19 for a discussion of the biology of primary headaches). Chapter 17 outlines diagnostic criteria for migraine, tension-type headache, and cluster headache, the three most common headache syndromes. In this chapter, we comment on differential diagnosis, diagnostic testing, and management of patients with these common primary headache disorders.


The two most common patterns of migraine are migraine with aura, formerly called classic migraine, and migraine without aura, or common migraine. Approximately 18% of women and 6% of men in the United States are plagued by migraine, and 15% will experience an aura with some of their migraine attacks.1


Clinical Features and Differential Diagnosis


Blau has described five phases of migraine that are not universally present and may variably occur during different attacks in the same individual.2 The first phase, or prodrome, occurs in 40% to 60% of migraineurs. It consists of altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for chocolate, or other vegetative symptoms, all of which suggest origin of these symptoms in the hypothalamus, perhaps as a result of excessive dopamine stimulation. These symptoms usually precede the headache phase of the migraine attack by several hours or even days, and experience teaches the patient or observant family that the migraine attack has begun.


The second phase of migraine is the aura, consisting of either visual or sensory phenomena (the two most common aura symptoms) or motor weakness, incoordination, or dysphasic symptoms, such as word-finding difficulty. The aura symptoms usually precede the headache phase of the migraine attack, but occasionally occur simultaneously. Sometimes, two aura symptoms occur in the attack, usually visual and sensory symptoms that may occur simultaneously or consecutively. The aura symptoms appear gradually over 5 to 20 minutes and usually subside just before the headache begins.


When examining a patient who has recently experienced only one or two such attacks for the first time, the clinician must determine whether these focal neurologic symptoms represent migrainous aura or manifestations of transient ischemic attack (TIA) or even a focal sensory seizure. Passage of time, ...

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