Feature Article

Unusual primary headaches: keys to an accurate diagnosis

Elspeth Hutton, Richard Stark



A patient presents to you with recurrent headaches that don’t quite fit the pattern of migraine or tension-type headaches. Which disorders should you consider?

Key Points

  • Primary headache disorders other than migraine and tension-type headache are less well known; however, not all are rare and they will be encountered occasionally in general practice.
  • The trigeminal autonomic cephalgias (TACs) are short-lasting headaches with prominent autonomic features and should be differentiated from short-lasting headaches without autonomic features.
  • Photo- and phonophobia are usually unilateral in TACs, but are bilateral in migraine, even when the pain is lateralised.
  • Autonomic symptoms tend to be lateralised to the side of the pain, prominent, and consistent between attacks in TACs; in migraine, they are generally mild, bilateral and do not parallel attack severity.
  • The diagnosis of other recurrent primary headache disorders is often suggested by the specific trigger factors (e.g. sexual activity, exertion, or coughing) or specific features of the pain (e.g. local, brief stabbing pain, or focal coin-shaped area of pain).