2018 / 11 January

Benign primary headaches

Headache is defining as a pain or discomfort arising from pain-sensitive structures in the head. It’s the fifth most common primary complaint of patients presenting to an emergency department (ED) in the United State and patients with headache constitute up to 4.5 percent of emergency department visit and the overwhelming majority will have benign primary headaches, such as a migraine, tension, or cluster. Headache affects people of all ages, races and socioeconomic status and is more common in women.

Cluster headache

  • It’s a neurovascular headache disorder
  • Patient experiences one or two cluster periods per year, each lasting 2 weeks to 3 months
  • Attacks of severe or very severe, unilateral pain (orbital, supraorbital, or temporal pain) and associated with one or more of the following conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, forehead and facial sweating, miosis and/or ptosis, eyelid edema, and a sense of restlessness or agitation (as many as 90% of patients may become agitated)
  • Triptans and oxygens are the first-line abortive agents used in the treatment of cluster headache and calcium-channel blockers may be the most effective agents for cluster headache prophylaxis


  • Recurrent episodes of headaches
  • Most often unilateral
  • Associated with visual or sensory symptoms (known as an aura) that most often arise before the head pain
  • Triptans such as Sumatriptan, are often the first-line abortive agents used in the treatment of migraines with about 70% efficacy in adults. Triptans should not be used more than 3 days weekly
  • The results of nonpharmacologic management results are similar to those of preventive drug use in terms of average reduction of migraines

Choosing Wisely: 5 Headache Interventions Discouraged

Tension-type headaches

  • Associated with a stressful event
  • More common in women
  • Moderate intensity and self-limited
  • Nonpulsatile quality
  • Not aggravated by physical activity
  • Usually responsive to nonprescription drugs
  • Associated with contracted muscles of the neck and scalp
  • This type of headache is bilateral and usually occipitofrontal


  • Bigley GK. Headache. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 54. Available from: https://www.ncbi.nlm.nih.gov/books/NBK377/
  • Ahmed F. Headache disorders: differentiating and managing the common subtypes. British Journal of Pain. 2012;6(3):124-132. doi:10.1177/2049463712459691. (link)
  • Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache.Headache. 2018 Feb;58(2):339-345. doi: 10.1111/head.13067. (link)
  • Weatherall MW. The diagnosis and treatment of chronic migraine. Therapeutic Advances in Chronic Disease. 2015;6(3):115-123. doi:10.1177/2040622315579627. (link)
  • Chowdhury D. Tension type headache. Annals of Indian Academy of Neurology. 2012;15(Suppl 1):S83-S88. doi:10.4103/0972-2327.100023. (link)

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