Accepted

The vast majority of headache patients encountered in the outpatient general medicine setting will be diagnosed with a primary headache disorder, mostly migraine or tension-type headache. Other less common primary headaches and secondary headaches, related to or caused by another condition, are the topic of this article. Nonmigraine primary headaches include trigeminal autonomic cephalalgias, primarily cluster headache; facial pain, primarily trigeminal neuralgia; and miscellaneous headache syndromes, such as hemicrania continua and new daily persistent headache. Selected secondary headaches related to vascular disease, cerebrospinal fluid dynamics, and inflammatory conditions are also reviewed.

Migraine and tension-type headache are highly prevalent. Migraine is associated with significant work- and family-related disability. Migraine is underdiagnosed; it reasonable to err on the side of migraine when choosing between primary headaches. Barriers to appropriate treatment of migraine include lack of access to providers, misdiagnosis, and acute and preventive therapies not being prescribed. Acute, rescue, and preventive treatment options are extensive, and new classes of treatments are either available or in development. This review addresses diagnostic challenges including recognizing migraine with aura. It also summarizes nonpharmacologic, acute, rescue, and preventive treatment options for migraine and treatment of tension-type headache.

Introduction Neuromodulation techniques play an increasing role in the treatment of primary headaches. While initially reserved for refractory cases they are now increasingly taken into consideration in earlier treatment phases and in non-refractory situations. One of the main reasons of this paradigm shift is that most neuromodulation techniques are better tolerated as compared to the majority of pharmacological approaches. However, these techniques have their limitations that should be considered. Areas covered The review provides an overview of the available techniques and their therapeutic rationale as well as on the evidence for their efficacy and their limitations. The review covers these aspects for non-invasive vagal nerve stimulation, sphenopalatine ganglion stimulation, external trigeminal nerve stimulation, occipital nerve stimulation as well as single-pulse and repetitive-pulse transcranial magnetic stimulation. Expert commentary Most of the evidence is based on open-label studies. Sham devices used in controlled studies remain problematic as they either do not produce the paresthesias perceived during stimulation or induce some degree of stimulation. Invasive techniques require a surgical intervention with all the potential complications that may arise. In summary some of the techniques provide an effective expansion of available treatment options but their indication should be thoroughly evaluated before treatment is considered.