What are the key features in the history and examination that help differentiate between primary and secondary headaches?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 22 August 2025Updated: 22 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

Key features in history and examination that differentiate primary from secondary headaches include:

  • Onset and progression: Primary headaches (such as migraine, tension-type, and cluster headaches) typically have a gradual onset and characteristic patterns, whereas secondary headaches often have a sudden onset, especially if reaching maximum intensity within 5 minutes (thunderclap headache), which is a red flag for serious causes like subarachnoid haemorrhage ,.
  • Associated symptoms: Primary headaches may have typical associated symptoms such as aura in migraine (fully reversible neurological symptoms developing over 5 to 60 minutes), photophobia, nausea, or autonomic features in cluster headache (e.g., red watery eye, nasal congestion) . Secondary headaches may present with systemic symptoms like fever, neck stiffness, altered consciousness, or new neurological deficits ,.
  • Neurological examination: Normal neurological examination is typical in primary headaches, while new-onset neurological deficits, cognitive dysfunction, or personality changes suggest secondary causes .
  • Triggers and exacerbating factors: Secondary headaches may be triggered by cough, Valsalva manoeuvre, exercise, or posture changes (orthostatic headache), which are uncommon in primary headaches .
  • History of trauma or systemic illness: Recent head trauma, compromised immunity, or history of malignancy raise suspicion for secondary headaches .
  • Headache characteristics: Primary headaches have characteristic pain locations and qualities (e.g., bilateral pressing pain in tension-type headache, unilateral pulsating pain in migraine, unilateral severe pain around the eye in cluster headache) . Secondary headaches often have atypical or changing headache patterns .

Summary: A careful history focusing on headache onset, associated symptoms, triggers, systemic features, and neurological examination findings helps differentiate primary headaches from secondary headaches that require urgent investigation or referral ,.

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