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Primary and Secondary Headaches

Headaches specialists generally divide headaches into two types: primary and secondary.

Primary headaches are far more common than secondary headaches. By definition, these headaches are “idiopathic” — occurring for no obvious reason, not the result of any other underlying disease or process. It will likely turn out that these conditions have a complex interplay of genetic, developmental, and environmental risk factors.

Common primary headaches include migraine, tension-type, and cluster. Because these headaches by definition are not being caused by any underlying problem, neurological examinations and imaging tests are usually completely normal in these disorders, no matter how severe the symptoms. Thus there are no tests for these headaches, only tests to rule out other causes. Increasingly, we think of these headaches as a result of a problem with brain function rather than brain structure. While painful or even disabling, primary headaches are almost never dangerous in and of themselves.

Secondary headaches are the ones that are more worrisome. They may be the result of serious underlying diseases or other conditions ranging from brain tumors, to aneurysms, to inflammatory diseases, to abnormalities of the spinal fluid. While they are relatively rare, it is important to recognize these types of headaches because the underlying disease causing the headaches may require urgent diagnosis and treatment. Even if the underlying disease is not particularly threatening, secondary headaches generally will not resolve until the specific cause is diagnosed and addressed.

Each patient’s headaches requires careful diagnostic assessment to determine whether or not there is an underlying cause. The Johns Hopkins Headache Center providers are well versed in recognizing, ruling-out, diagnosing, and managing a wide variety of secondary headaches.

What are the warning signs or symptoms of Secondary Headaches?

Certain warning signs or symptoms may suggest to your provider that you have a potentially dangerous secondary headache, prompting additional workup after your initial visit. These include:

  • Neurological symptoms during or between headaches
  • Abnormal neurological examination
  • New or unusual type of headache
  • Older age - 50 (or 60+)
  • Immunocompromised state (HIV, chemotherapy)
  • Sudden or worst headache of your life
  • Fever
  • Stiff neck
  • Swelling of the optic nerves
  • Headaches not responding to treatment / steadily worsening

In the presence of any of these signs or symptoms, your diagnostic assessment may include blood tests, brain scans, a lumbar puncture, or referral to another specialist.

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Pediatric Neurosurgery: 410-955-7337


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