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Headache assessment and primary-headache classification

US-focused secondary-headache triage, phenotype diagnosis, selective testing, medication-overuse prevention and follow-up.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team 路 Clinical editorial review 路 reviewed 2026-08-20 路 due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Adolescents and adults with a new or recurrent headache in outpatient or urgent care. This page covers initial classification and safety, while the companion migraine page addresses acute and preventive treatment in more depth. Children, pregnancy, recent trauma, immunocompromised hosts and known intracranial disease require age- or condition-specific thresholds.
sources for this section:VA/DoD headache 2023

The Bottom Line

  • Decide first whether the history or examination suggests a dangerous secondary cause; do not label a new severe syndrome as primary headache before addressing red flags.
  • For a stable recurrent headache with a typical primary phenotype and normal neurologic examination, avoid routine neuroimaging or broad laboratory testing that is unlikely to change management.
  • Classify migraine, tension-type, cluster or another syndrome from attack duration, location, quality, associated symptoms, triggers and interictal pattern, using a headache diary when recall is unreliable.
  • Count both headache days and acute-medication days, because frequent rescue treatment can perpetuate medication-overuse headache and alter the preventive-treatment decision.
sources for this section:VA/DoD headache 2023

Practical clinical workflow

1
Document onset speed, first or worst status, age at onset, progression, positional or exertional triggers, fever, cancer, immune status, pregnancy, trauma, neurologic symptoms and current medicines.
2
Measure blood pressure and perform a focused neurologic, funduscopic and neck examination when indicated; evaluate temporal arteries, sinuses, teeth or eyes only when the phenotype supports them.
3
If a primary syndrome is likely, explain the diagnosis, identify modifiable triggers without imposing unnecessary restrictions, establish an acute plan and determine whether prevention is warranted.
4
Arrange follow-up to review diary data, disability, treatment response, adverse effects and diagnostic evolution; refer unusual, progressive, refractory or uncertain headache to an appropriate specialist.
sources for this section:VA/DoD headache 2023

Safety boundaries and escalation

  • Thunderclap onset, meningism, fever with altered mental status, papilledema, focal deficit, seizure or a painful red eye requires urgent evaluation rather than a routine primary-headache plan.
  • A new headache during pregnancy or postpartum, with cancer or immunocompromise, after head trauma or after age-related pattern change needs a lower threshold for targeted investigation.
  • New monocular vision loss, jaw claudication or scalp tenderness in an older adult requires immediate assessment for giant-cell arteritis and vision-preserving treatment.
  • Do not use opioids as routine headache rescue; repeated sedating or dependence-forming treatment increases harm and can complicate medication-overuse withdrawal.
sources for this section:VA/DoD headache 2023

Localization

The 2023 VA/DoD guideline is a federal US evidence source and applies beyond military settings only with clinical judgment. State emergency access, imaging availability and controlled-substance rules vary.
sources for this section:VA/DoD headache 2023

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. U.S. Department of Veterans Affairs and U.S. Department of Defense Evidence-Based Practice Work GroupVA/DoD Clinical Practice Guideline for Management of Headache2023 guideline; official page updated 2025-07-11 路 published 2023-09-01 路 updated 2025-07-11 路 accessed 2026-08-20
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