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A Comprehensive Review

Gerald W. Smetana, MD

Arch Intern Med. 2000;160:2729-2737.

Background  Existing criteria for the diagnosis of headache do not indicate which clinical features are most important to establish or exclude primary headache diagnoses.

Objective  To determine the value of history taking in the evaluation of patients with primary headache syndromes.

Methods  A MEDLINE search of English-language studies published since 1966 and a hand search of bibliographies from retrieved articles. Included studies cited the sensitivity of clinical and historical features for the diagnosis of migraine, tension-type, and cluster headaches. Studies were classified according to their use of the International Headache Society criteria or other criteria as the reference standard for diagnosis.

Results  The features most predictive of migraine, when compared with tension-type headache, are nausea, photophobia, phonophobia, and exacerbation by physical activity. Positive likelihood ratios (95% confidence intervals) are 19.2 (15.0-24.5), 5.8 (5.1-6.6), 5.2 (4.5-5.9), and 3.7 (3.4-4.0), respectively. Headache precipitants are present equally in patients with migraine and tension-type headache, with the exception of food triggers, which confer a positive likelihood ratio of 3.6 (2.8-4.6) for the diagnosis of migraine. Visual aurae are present in 84% of patients with migraine with aura. Cluster headache is strictly unilateral, is periorbital in 80% of patients, and lasts less than 1 hour in 54% of patients.

Conclusions  The features most predictive of the diagnosis of migraine, when compared with tension-type headache, are nausea, photophobia, phonophobia, exacerbation by physical activity, and an aura. Cluster headache is a distinct clinical syndrome.

From the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Mass.

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