Top six headaches in primary care


Raeburn Forbes  2012                                                        updated jan 2013

Episodic tension type headache (includes temporary headache associated with a self-limiting fever)

Up to 80% of people per annum have a single episode of this, and usually do not consult
Episodic Mild-Moderate Headache
Pain free between

Usually bilateral on top/front/sides of head
Occasional mild nausea or mild intolerance of noise, but not to the same extent as for migraine
NB- Can have a cervicogenic element - pain from facet joints can mimic TTH, and radiate to top or side of head, in which case physiotherapy may be an option


Cervicogenic Headache

6% of men, 16% of women per annum

Episodes of Moderate-Severe Headache

Pain free between

Pulsing or throbbing quality

Sensory Sensitivity Present i.e. one or more of

1.Nausea or Vomiting

2.Intolerance of light / prefer dark

3.Intolerance of noise / prefer quiet

4.Intolerance of smell / anorexia

5.Intolerance of movement / prefer to lie

6.Intolerance of contact / prefer to be alone

About 10-15% will also have migraine aura*(see below)

Ice-pick Headache

Chronic Tension Type Headache

Chronic Migraine

4% of adults per annum
Periods of constant – non-pulsatile pain, lasting days to weeks:
Often Unilateral, and locked to one side
Can be back of head, top of head - and sound just like TTH
Will radiate to forehead, temple, ear
Often worse after lying / driving
Tenderness craniocervical junction, especially c1/2, c2/3 facet joints Often previous history of whiplash, head injury, occupation-related poor posture or osteoarthritis
Limited range of neck rotation or flexion/extension
Can have superimposed shorter episodes of sharp or shooting pain Physiotherapist can identify affected joints using Passive Accessory Intervertebral Movements (PAIVMs)

At least 1% (some estimates up to 35%!) per annum
Brief neuralgiform headaches
Maximal within a split second
Last no more than a few seconds at high intensity but can leave a residual dull sensation for minutes afterwards.Often in the eye or above the eye.
The intensity of pain will sometimes make people wince, feel weak at the knees or clutch their head. More common in people with migraine or cluster headaches and occur in people with cervicogenic headache

1% of adults each year
Same as Episodic Tension Type Headache but occurs on a majority of days for more than 3 months
Medication overuse, depressive disorders or psychosocial stressors

Cervicogenic aetiology is probably worth exploring

0.1-0.2% of adults
(2% of people with migraine each year get a phase of chronic migraine) Bouts of moderate-severe migraine which never seem to resolve. Background daily ache or pressure – “head never clear”
Can have intolerance of light, noise, movement without severe headache periods
Overuse of analgesic medication or triptans and OOH attendances Psychosocial stressors.
Co-morbid anxiety and/or depression