Introduction

Nearly everyone will experience headaches at some time in their lives. Most headaches are trivial, with an obvious cause and minimal associated disability. However, some headaches are sufficiently troublesome that the person seeks medical help. Headache accounts for 4.4% of consultations in primary care (6.4% females and 2.5% males). Unless a correct diagnosis is made, it is not possible to provide the most effective treatment. For most medical ailments the suspected diagnosis can be confirmed with tests, but no diagnostic test can confirm the most common headaches, such as migraine or tension-type headache. This means that unless the headache is obvious, diagnosis is largely based on the history. In addition, the examination of people with primary headaches is essentially normal. Consequently, the diagnosis is not always easy, particularly if several headaches coexist, confusing both patient and doctor. In a study of patients with a diagnosis of migraine who were referred to a specialist migraine clinic, nearly one third had a headache additional to migraine. Failure to recognize and manage the additional headache was the most common cause of treatment failure.

It is not always possible to confirm the diagnosis at the first visit. A structured history, followed by a relevant examination, can identify patients who need immediate investigations or referral from the non-urgent cases. Management and follow-up will depend on whether the diagnosis is confidently ascertained or is uncertain.