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Headache

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Headache, an almost universal human experience, is one of the most common complaints encountered in medicine and neurology. Described and categorized since antiquity, with the first classification by Aretaeus of Cappadocia, other classifications followed. The evaluation of this condition may be straightforward or challenging, and, though often benign, headache may prove to be an ominous symptom. This review discusses the current diagnosis and classification of headache disorders and principles of management, with a focus on migraine, tension-type headache, trigeminal autonomic cephalgias, and various types of daily headache.

Ancient references to headache, migraine, and neuralgia can be found in the Ebers Papyrus (1200 B.C.), and evidence of trepanation of 9000 year old Neolithic skulls suggests the first headache treatment. Visual symptoms associated with headache were described by Hippocrates in 400 B.C., and Aretaeus provided one of the earliest classifications of headache around 200 AD.12

Interest in headache extends back almost as far as recorded history, and it is one of the most common complaints of patients who present for medical treatment. The direct and indirect socioeconomic costs of headache to society are estimated at $14 billion per year.3 All primary care providers will encounter the clinical problem of headache on a regular basis; early and accurate diagnosis and appropriate treatment will help to reduce pain and suffering and the economic burden.

Epidemiology

Lifelong prevalence of headache is 96%, with a female predominance. The global active prevalence of tension-type headache is approximately 40% and migraine 10%. Migraine occurs most commonly between the ages of 25 and 55 years and is 3 times more common in females.45 Despite the fact that it causes significant disability, migraine remains underdiagnosed and undertreated.

Trigeminal autonomic cephalgias are rare compared with migraine and tension-type headache. The most common trigeminal autonomic cephalgia is cluster headache, with a population prevalence of 0.1% and a male/female ratio of 3.5-7:1.67

Chronic daily headache, daily or near-daily headache for months to years, is widely reported in the literature, yet is not an official diagnosis in the International Classification of Headache Disorders. Chronic daily headaches of long duration include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Worldwide prevalence of chronic daily headache has been consistent at 3%-5%,4 most of which likely represents chronic migraine.

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-Paul Rizzoli, MD, FAHS, William J. Mullally, MD, FAHS

This article originally appeared in the January 2018 issue of The American Journal of Medicine.

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