Primary headache syndrome (tension headache, cluster headache, and migraine headache) refers to headaches which do not occur secondary to an underlying disease process.  Primary headaches account for most cases of cephalgia or head pain.  All patients who suffer from these headaches should undergo a complete physical and neurologic examination with a directed search for possible causes of secondary headache.  If an etiology for a secondary headache is suspected, the work up should proceed accordingly.  An ESR determination should be considered in patients greater than 60 years of age to evaluate for possible temporal arteritis.  If no secondary etiology is suspected after a thorough history and physical examination, then a primary headache syndrome is most likely, and an empiric trial of therapy may be instituted based on the suspected type of headache, either tension-type, migraine, or cluster.  Patients with primary headache syndromes may suffer an increase in the frequency or severity of their headaches when they use excessive doses of their abortive analgesic agents, a phenomenon called rebound headaches.

     Generally, a normal physical and neurologic examination makes further evaluation unnecessary; however, the presence of certain physical findings or symptoms may make neuroimaging or further testing (blood tests, lumbar puncture, etc.) prudent.  Findings that may signal a potentially lethal etiology include: age greater than 50 years old at onset of first headache, a new or different kind of headache, the “worst” headache a patient has ever experienced, subacute headaches that progressively worsen, headache with exertion, sexual activity, coughing or sneezing, or headaches associated with drowsiness, confusion, memory deficits, weakness, ataxia, loss of coordination, paresthesias, paralysis, sensory loss, meningeal irritation (positive Brudzinski or Kernig’s signs), asymmetric pupillary response, the presence of a Babinski sign, fever, hypertension, weight loss, prominent, tender, and poorly pulsatile temporal arteries, jaw claudication, papilledema, or symptoms consistent with a systemic illness.  An MRI is the preferred study; however, when a patient presents with an acute, severe headache, CT scanning without contrast is necessary to rule out intracranial hemorrhage.  If the CT is negative then lumbar puncture should be performed to further eliminate the possibility of subarachnoid hemorrhage.  An ESR should be obtained in patients greater than 50 years of age to eliminate the possibility of temporal arteritis.

     Tension type headaches are characterized by bilateral pain or pressure that is often compared to a “vise around the head”.  These patients usually lack the migraine associated symptoms of nausea, vomiting, photophobia, phonophobia, or increased symptoms with physical exertion.  However, even without the above mentioned associated symptoms, most recurrent headaches will prove to be migrainous.  Tension type headaches can be managed with analgesics to include acetaminophen, NSAIDs, butalbutal containing combination products or narcotics.  Be wary of initiating drug dependency or rebound headaches with excessive, frequent use of analgesic agents.  If there are associated cervical or suboccipital muscle tenderpoints, trigger point injection therapy with a lidocaine type anesthetic may prove effective in cases where headaches are recurrent.  Osteopathic or chiropractic manipulation of the cervical spine or upper ribs may also prove effective.  As with migraines, counsel patients to keep a headache diary to attempt to identify an aggravating factors which if eliminated would decrease the frequency of the headaches.

     Cluster headaches generally affect men between the ages of 20-40 and follow a cyclic pattern occurring daily for weeks or months.  The pain is usually severe, unilateral and localized to the orbital region.  Attacks reach maximal intensity in minutes and lasts from 15 minutes to 2 hours.  Associated symptoms may include ipsilateral ptosis, edema, conjunctivitis, rhinorrhea, and lacrimation.  Since the duration of pain is often brief, therapy is often unnecessary.  When patients do require therapy, treatment may include oxygen (7 L/min for 10 minutes), sumatriptan (6 mg SQ), or lidocaine (1 cc of 4% solution placed in the ipsilateral nostril).

     Two other types of primary headache syndromes are chronic paroxysmal hemicrania and hypnic headache.  Chronic paroxysmal hemicrania is clinically similar to cluster headaches; however, treatment is with indomethicin and not the above mentioned therapies for cluster headaches.  Hypnic headaches are similar to migraines but occur at night and are unresponsive to abortive migraine therapies.  Lithium therapy may prove effective in the treatment of hypnic headaches.