Migraine, Tension-Type, and Cluster Headache

Headache assessment begins with two decisions: does the story fit a primary headache pattern, and is there a reason to investigate a secondary cause? The most useful discriminators are the clock, pain phenotype, associated symptoms, cranial autonomic signs, and the patient's behaviour during an attack. Migraine, tension-type headache, and cluster headache can coexist, and frequent use of rescue medication can add medication-overuse headache to any of them. ICHD-3 thresholds prevent overcalling a diagnosis. Migraine without aura requires at least 5 attacks lasting 4–72 hours, at least 2 characteristic pain features, and either nausea/vomiting or both photophobia and phonophobia. Aura requires at least 2 attacks with fully reversible neurologic symptoms; typical symptoms spread gradually and last 5–60 minutes. Motor aura indicates hemiplegic migraine, a distinct subtype. A thunderclap or changed pattern, fever or systemic illness, focal neurologic deficit, papilledema, new headache later in life, pregnancy or puerperium, immunocompromise, trauma, positional or exertional provocation, or a painful red eye with visual change moves the patient out of routine primary-headache management. A red or painful eye with a mid-dilated or fixed pupil may...