Criteria For Headache Research Articles

Characteristics of headache during and after digital substraction angiography: A critical re-appraisal of the ICHD-3 criteria.

Introduction Headache is a frequent but neglected side effect of angiography, and the criteria for angiography related headache have been based on only a few studies. Methods One-hundred and thirty nine patients who underwent cerebral angiography and 30 controls who underwent peripheral angiography participated in this prospective, non-randomized, case-control study. Participants were instructed to tell the angiography staff in case a headache developed and were questioned about their headache just after, 24 hours after, and one week after angiography. Results In the cerebral angiography group 42 patients (30.2%) had procedural headache compared to three of the controls (10%). Two different types of headache related to angiography were observed: one during angiography, which was related to contrast injection, and the other occuring within 24 hours. Both headaches were more frequent in patients with a history of primary headache, but were distinctly different from the premorbid headache. Headache characteristics are described in detail. Discussion Both types of headache related to angiography did not match the ICHD-3beta criteria for angiography headache, but were similar to headaches reported in studies that were not included in the current criteria. The timing and characteristics of these headaches are discussed in the light of our and previous reports. We suggest that the present ICHD-3 beta criteria are inadequate in properly defining angiography headache and should be revised in the light of the present literature.

Headaches and pain referred to the teeth: frequency and potential neurophysiologic mechanisms

To assess frequency of pain referred to the teeth in occipital neuralgia, migraine and tension-type headache. Material and methods:153 patients presenting with bruxing behavior and craniomandibular disorders (CMDs). Clinical examination, questionnaires, palpation, criteria for CMDs, bruxing behavior (BB), occipital neuralgia (ON), migraine (MIG), tension-type headache (TTH) and pain referred to the teeth. Results: Mean ages in the ON, MIG and TTH patients and controls were about 38.0, 37.0, 33.0 and 36.6 years, respectively (p = 0.17). The frequencies of dental pains in the subgroups ON and MIG were 37.1% and 25% (p = 0.52), ON and TTH, 37.1% and 18.6% (p = 0.03), ON and Controls 37.1% and 6.7% (p = 0.006), MIG and TTH 25% and 18.6% (p = 0.51), MIG and Controls 25% and 6.6% (p = 0.16) and TTH and controls 18.6% and 6.7% (p = 0.15). The frequencies of pain referred to the teeth decreased from the ON to the MIG, and then to the TTH and Control groups (x-square for independence p < 0.002, x-square for trends p < 0.001). Conclusion:The ON subgroup demonstrated the highest frequency of dental pain referred to the teeth. This frequency increased with the severity of pain. Neurophysiological mechanisms may explain higher frequency of referred pain associated with the severity of headache.

Factores clínicos asociados con masa cerebral de novo en pacientes que ingresan con cefalea al departamento de urgencias

La cefalea constituye uno de los principales síntomas de consulta en el servicio deurgencias y constituye un desafío para el médico. Objetivo: Determinar los factoresclínicos que están asociados con la presencia de masa cerebral en pacientes que debutancon cefalea. Metodología: Estudio retrospectivo de casos y controles. Se definió como caso cada paciente que consultó por cefalea con evidencia imagenológica por tomografía axial computarizada (TAC) o resonancia nuclear magnética (RMN)de masa cerebral. Los controles fueron pacientes con cefalea sin evidencia imagenológica de masa cerebral. El tamaño de muestra fue de 272 pacientes (62 casos y 210 controles).Para determinar los factores asociados al desenlace se realizó un análisis de regresión logística binaria, incluyendo variables plausibles con p < 0,2 en el análisis bivariado y aquellas biológicamente plausibles. Se calcularon los odds ratio ajustados (ORA) y sus respectivos intervalos de confianza. Se consideró significativo un valor de p < 0,5. Resultados: Las variables clínicas asociadas con la presencia de masa cerebral fueron: 1) antecedente de cáncer fuera del sistema nervioso central, 2) cefalea que empeora con las maniobras de Valsalva, 3) alteraciones en el examen motor y 4) cefalea que despierta al paciente en la noche. Conclusiones: Se encontró que las variables mencionadas constituyen signos de alarma predictivos de la presencia de cefalea secundaria a masa cerebral y son importantes en la evaluación de todo paciente que consultapor cefalea en el servicio de urgencias y pueden orientar para la toma de decisiones.

Cefalea rinógena por contacto mucoso con solución quirúrgica. Descripción de un caso

Introduction and objective: Rhinologic headache caused by mucosal contact is a difficult definition condition with good response to surgical approach. Description: We present a case of a 31 year-old male with rhinologic headache criteria. We decided to offer a surgical approach, successfully. Discussion: Rhinologic headache is included in the group of “Headache caused by disorders of the nasal mucosa, turbinates or septum”. There is no agreement about its cause because the prevalence of mucosal nasal contact is similar in patients with and without facial pain. There is evidence in the resolution of facial pain with a surgical approach. Conclusions: Despite the evidence of success in the surgical approach, some doubts still persist about the causes of this entity.

Field testing primary stabbing headache criteria according to the 3rd beta edition of International Classification of Headache Disorders: a clinic-based study.

BackgroundThe diagnostic criteria for primary stabbing headache (PSH) in the 3rd beta edition of International Classification of Headache Disorders (ICDH-3 beta) were recently revised. In the ICDH-3 beta, PSH is defined as short-lasting head pain spontaneous occurring as a single stab or series of stabs without autonomic symptoms and involving all head areas (i.e., not limited to the ophthalmic branch region of the trigeminal nerve). The aim of this study was to investigate the validity of the ICHD-3 beta criteria for PSH in a clinic-based setting.MethodsWe prospectively collected data from patients with complaint of headache with stabbing pain without apparent cause at an initial visit to a secondary-care hospital from March 2009 to March 2014. Patients were followed up for 2 weeks to assess changes in clinical characteristics and secondary causes of pain.ResultsData from 280 patients with headache with stabbing pain without apparent cause were collected, and 245 patients were followed up for 2 weeks. Secondary causes for stabbing headache were observed in 9 patients (herpes zoster in 7 patients and Bell’s palsy in 2 patients) after 2 weeks. The remaining 236 patients fulfilled the diagnostic criteria for PSH according to ICHD-3 beta. Only 22 patients met the diagnostic criteria for PSH according to ICHD-2.ConclusionsAll patients with headache with stabbing pain without cranial autonomic symptoms fulfilled the diagnostic criteria for PSH according to ICHD-3 beta at the initial visit. Secondary causes for headache with stabbing pain were revealed in a small proportion (3.7 %) of patients after 2 weeks of follow-up.

Primary Headache in Children and Adolescents: From Pathophysiology to Diagnosis and Treatment

Primary headaches are common disorders among children and adolescents; tension type headaches (TTH) and migraine being the most frequent types. This paper reviews the literature and summarizes the knowledge regarding the underlying pathophysiological mechanisms that cause headaches, mainly TTH and migraine, discusses the diagnostic criteria for primary headaches, and the different moralities for management of pain in children and adolescents. It is well accepted, that the pain experience holds bio-psychosocial components to it, therefore treatment strategies should be tailored according to the patient’s age, headache diagnosis, family structure, culture and beliefs, and according to the disability the headache imposes on the patient’s daily living. A multidisciplinary treatment, that includes counseling, education and reassurance combined with pharmacological and non-pharmacological treatment, was found to be the effective strategy to alleviate the symptoms of primary headaches in children and adolescents.

Headache attributed to temporomandibular disorders and masticatory myofascial pain.

We investigated the temporal association between temporomandibular disorders (TMD)-related symptoms and headache during TMD treatment for patients who fulfilled the diagnostic criteria for headache attributed to TMD (HATMD) specified in the Diagnostic criteria for TMD (DC/TMD) and International classification of headache disorders (ICHD)-3 beta. The study enrolled 34 patients with HATMD induced by masticatory myofascial pain but not by temporomandibular arthralgia. Facial pain intensity, the pressure pain threshold of pericranial muscles, and maximum unassisted opening of the jaw were assessed at an initial examination and before and after physical therapy. The intensity and frequency of headache episodes and tooth contact ratio were also recorded before and after the intervention. Headache intensity and frequency significantly decreased, and these reductions were temporally related to improvements in facial pain intensity, maximum unassisted opening, and pressure pain threshold during TMD treatment. Linear regression analysis showed significant correlations between facial pain intensity and headache intensity and between tooth contact ratio and pressure pain threshold. Among patients who fulfilled the DC/TMD and ICHD-3 beta diagnostic criteria for HATMD, headache improved during TMD treatment, and the improvement was temporally related to amelioration of TMD symptoms. These findings suggest that sensitization in the central and peripheral nervous systems is responsible for HATMD. (J Oral Sci 58, 195-204, 2016).

O035. Headaches in Mitochondrial Disorders.

Methods We studied all consecutive patients referred to our Neuromuscular Unit, during a 6-month period. Ninetythree patients (aged 15 to 78 years, 31 males) with a typical phenotype of MCDs, underwent a structured diagnostic headache interview, using an operational diagnostic tool following the IHS criteria. If they met the criteria for primary headache, they were included in the “Headache Group” (HEAD+). The other patients were collected in the “No Headache Group” (HEAD-). Clinical, neuroradiological, and neurophysiological data were compared between groups. Mann-Whitney U-test was used to analyze numeric variables; Fisher’s exact test was used to analyze nominal variables. Binary logistic regression analysis was performed to identify risk factors of headache.

P048. Thunderclap headache as presentation of ischemic posterior circulation stroke.

We describe the case of a man who presented with an episode fulfilling the ICHD-III criteria for thunderclap headache (TH), whose diagnostic work-up led to an unexpected diagnosis.

Headache and psychopathology: DSM-V vs ICHD-3β vs ICD10.

A strict relationship between migraine and psychiatric factors has been suggested, but the exact role and the influence on evolution of headache is unknown. The most frequent diagnosis was a comorbidity of anxiety and mood disorders. The comorbidity of psychiatric disorders and headache has important implications as far as treatment is concerned. In comparing DSM-V, ICHD-3β and ICD10 criteria on headache and psychopathology, diagnostic criteria agree on pre-existing headache with the characteristics of a primary headache disorder becoming chronic, or made significantly worse, in close temporal relation to a psychiatric disorder, both in the initial headache diagnosis and psychiatric diagnosis. Headache attributed to psychiatric disorder should be given, provided that there is good evidence that that disorder can cause headache. When a causal relationship cannot be confirmed, the pre-existing primary headache and the psychiatric disorder are diagnosed separately. Thus, the diagnostic categories are limited to those few cases in which a headache occurs in the context and as a direct consequence of a psychiatric condition known to be symptomatically manifested by headache. Diagnostic criteria must be restrictive enough not to include false positive cases, but must set the threshold low enough to admit the majority of affected patients. Headache disorders occur coincidentally with a number of psychiatric disorders. Although criteria for headaches attributed to psychiatric disorders have suggested that headache occurring exclusively in association with several common psychiatric disorders, such as, depressive, anxiety and trauma/stress-related disorders, might be considered as attributed to these disorders, because of uncertainties concerning the causal relationships and relative lack of evidence in this context. Evidence suggests that the presence of a comorbid psychiatric disorder tends to worsen the course of migraine and/or tension-type headache by increasing the frequency and severity of the headache and/or making it less responsive to treatment. Thus, identification and treatment of any comorbid psychiatric condition is important for the proper management of these headaches. It should be noted that somatization disorder per se is not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), it has been replaced by the category Somatic Symptom Disorder, characterized by one or more somatic symptoms. Thus, ICHD-3 beta continues to refer to the DSM-IV definition of somatization disorder. Using WHO's criteria and methods for measuring burden of disease in DALYs, headache disorders can be placed correctly in the context of other mental and neurological disorders and other chronic illnesses. In order to know the full burden attributable to headache disorders, however, further epidemiological work must be conducted around the world and this must encompass assessments of clinical, economic and humanistic impacts.

P024. Features of headache attributed to carotid and vertebral arteries dissection.

Headache and cervical pain are common but not specific symptoms of carotid and vertebral arteries dissection. It is difficult to identify a specific pattern of pain due to dissection, useful to correctly address the diagnosis of dissection at first clinical evaluation, if other neurological signs (e.g., cranial nerves deficit, Horner's syndrome and other signs of cerebral ischemia) are not present. Recently, in the third edition of the International Classification of Headache Disorders (ICHD-III beta) diagnostic criteria for headache attributed to arterial dissection have been modified. Some Authors have suggested that this new classification is more reliable to detect carotid or vertebral arteries dissection at first clinical evaluation. Some headache features, such as, acute onset, continuous lasting and time-persistence, are currently emphasized. We have retrospectively investigated 34 patients diagnosed from January 2012 to March 2015 with cervical artery dissection. Our aim was to identify the main features of headache attributed to arterial dissection, in our cohort of patients, according to the new ICHD-III beta. We enrolled 34 patients (20 females; mean age 56 ± 11; age range 31-83), 20 of them with headache. In 10 of these 20 patients, headache was the unique symptom.

Evaluation of the new ICHD-III beta cluster headache criteria.

In the revised criteria of the International Classification of Headache Disorders (ICHD-III beta) the following items are added to the diagnostic criteria of cluster headache: ipsilateral sensation of fullness in the ear and ipsilateral forehead/facial flushing. We evaluated the possible additional value of these symptoms for diagnosing cluster headache. In this cross-sectional cohort study of (potential) cluster headache patients we investigated these additional symptoms using a Web-based questionnaire. Patients not fulfilling the ICHD-II criteria for cluster headache but fulfilling the ICHD-III beta criteria were interviewed. Response rate was 916/1138 (80.5%). Of all 573 patients with cluster headache according to ICHD-II criteria, 192 (33.5%) reported ipsilateral ear fullness and 113 (19.7%) facial flushing during attacks. There was no difference in reporting ipsilateral ear fullness and facial flushing between patients who received a diagnosis of cluster headache and patients who did not. None of the patients who did not fulfill all ICHD-II criteria could be categorized as cluster headache according to the ICHD-III beta criteria. The results of this study do not support the addition of ear fullness and facial flushing to the new ICHD-III beta criteria.

Intracranial Hypertension Without Papilledema in Children.

This study aims to determine the frequency of intracranial hypertension without papilledema in children. Charts of patients evaluated in a pediatric intracranial hypertension clinic at our institution were retrospectively reviewed. The patients were divided into 2 groups depending on whether they had presence or absence of optic nerve edema at the time of presentation. Age, body mass index, and opening cerebrospinal fluid pressures were considered continuous variables and compared by Wilcoxon rank sum test because of non-normality. A P-value of 0.05 was considered significant. A total of 228 charts were reviewed; 152 patients met the criteria for intracranial hypertension, and 27 patients (17.8%) met the criteria of headache without optic nerve edema. There was no clinically significant difference in age, body mass index, opening pressure, and modified opening pressure between the 2 groups.

Frequency of Migraine Headaches in Patients With Fibromyalgia.

The purpose of this study was to evaluate the frequency of migraine headache in a large cohort of patients with fibromyalgia using a brief migraine headache-screening tool. Several studies report a high prevalence of fibromyalgia among patients with migraine headaches, but there is a dearth of research evaluating the frequency of migraine headaches in patients with fibromyalgia, despite clinical observations suggesting that migraine headaches are common in patients with fibromyalgia. This was a cross-sectional survey study. Patients (N = 3717) with a previous diagnosis of fibromyalgia who were members of the Mayo Clinic Fibromyalgia Registry were contacted by electronic survey and asked to complete a brief demographic and medical history questionnaire and the validated ID-Migraine screener. A total of 1730 patients (46.5%) completed the electronic survey. The majority of participants were white (97.2%), female (92.5%), with a mean age of 56.2 (±13.1) years. Of the respondents, 966 (55.8%) met criteria for migraine headaches. Hypertension (309 [32.3%] vs. 294 [40.1%], P = .004), asthma (312 [32.5%] vs. 189 [25.9%], P = .011), irritable bowel syndrome (520 [54.6%] vs. 348 [47.6], P = .017), chronic fatigue syndrome (486 [50.7%] vs. 271 [37.1], P < .0001), depression (634 [66.5%] vs. 413 [56.7%], P = .0002), anxiety (415 [43.5%] vs. 252 [34.7%], P = .0011), and post-traumatic stress disorder (172 [18.0%] vs. 96 [13.2%], P = .006) were all significantly more common in those who met criteria for migraine headaches than those who did not. The results of this study suggest that migraine headaches are common in patients with fibromyalgia. Clinicians who care for either population must be aware that these conditions commonly overlap and can significantly increase a patient's cumulative disease burden.

Headache attributed to intracranial pressure alterations: applicability of the International Classification of Headache Disorders ICHD-3 beta version versus ICHD-2.

The association between headache and changes in intracranial pressure is strong in clinical practice. Syndromes associated with abnormalities of cerebrospinal fluid (CSF) pressure include spontaneous intracranial hypotension (SIH) and idiopathic intracranial hypertension (IIH). In 2013, the Headache Classification Committee of the International Headache Society (IHS) published the third International Classification of Headache Disorders (ICHD-3 beta version). The aim of this study was to investigate applicability of the new ICHD-3 versus ICHD-2 criteria in a clinical sample of patients with intracranial pressure (ICP) alterations. Patients admitted at our Headache Center for headache evaluation in whom a diagnosis of ICP alterations was performed were reviewed. 71 consecutive patients were studied. 40 patients (Group A) were diagnosed as IIH, 22 (Group B) as SIH, 7 (Group C) and 2 (Group D), respectively, as symptomatic intracranial hypertension and symptomatic intracranial hypotension. Main headache features were: in Group A, daily or nearly-daily headache (100 %) with diffuse/non-pulsating pain (73 %), aggravated by coughing/straining (54 %) and migrainous-associated symptoms (43 %). In Group B, an orthostatic headache (100 %) with nausea (29 %), vomiting (24 %), hearing disturbance (33 %), neck pain (48 %), hypacusia (24 %), photophobia (22 %) was reported. In Group C, a diffuse non-pulsating headache was present in 95 % with vomiting (25 %), sixth nerve palsy (14 %) and tinnitus (29 %). In Group D, an orthostatic headache with neck stiffness was reported by 100 %. Regarding applicability of ICHD-2 criteria in Group A, 73 % of the patients fitted criterion A; 100 %, criterion B; 100 %, criterion C; and 75 %, criterion D; while applying ICHD-3 beta version criteria, 100 % fitted criterion A; 97.5 %, criterion B; 100 %, criterion C; and 100 %, criterion D. In Group B, application of ICHD-2 showed 91 % patients fitting criterion A; 100 %, criterion B; 100 %, criterion C; and 68 %, criterion D; while applying ICHD-3 beta version all patients, 100 % fitted criterion A, B, C, D. 73 % patients of Group A fitted all ICHD-2 criteria and 97.5 % all ICHD-3 beta version criteria for headache attributed to IIH. 68 % patients of Group B fitted all ICHD-2 criteria and 100 % all ICHD-3 beta version criteria for headache attributed to SIH. In Group C and Group D, although patients fitted some clinical criteria, the underlying disorder caused exclusion of both ICHD-2 and ICHD-3 beta version applicability for headache attributed to IIH and SIH; they were coded in criteria for the secondary headaches. In summary, ICHD-3 beta version seems to have better applicability but worse reliability in defining headache features in CSF alterations.

Description of series of 10 patients with hypnic headache: discussion of the diagnostic criteria

IntroductionHypnic headache is a rare primary headache. The diagnostic criteria of the International Headache Classification (IHS) for this condition are discussed, as they have been modified in the new edition of the 2013. Patients and methodsThe clinical characteristics, and fulfilment of the criteria of the IHS classification in a series of 10patients diagnosed in our Headaches Clinic, are analysed. ResultsThe mean age of onset of symptoms was 52.1years (SD: 13.4; range: 28–69). The pain was reported as oppressive in 60% of the patients, and as sharp in 30%. The headache was described as holocranial in 60% and hemicranial in 40%. They occurred exclusively during night-time sleep in 80% of the patients. The mean duration of headache was 136.5minutes (range: 10–480). The mean number of days per month was 16.4 (range: 3–30), and 50% had less than 15 headache days per month. No patient had autonomic manifestations, 70% had phonophobia, 50% had photophobia, and 50% had both. All of them (100%) had a VAS score equal to or higher than 8. ConclusionsThe criteria for hypnic headache of the new classification are best suited to the characteristics of these patients. Our results show the major changes in the criteria: pain is not always dull, headache frequency may be less than 15days a month, and it can occur in people under age 50. There may be phonophobia or photophobia only, or both. Although it does not form part of the diagnostic criteria, the pain intensity in our series was higher than described.

Cervicogenic headache: too important to be left un-diagnosed.

A comparison has been made between the cervicogenic headache criteria in the new IHS classification of headaches (3rd edition- beta version) and The Cervicogenic Headache International Study Group’s (GHISG) criteria from 1998. In a more recent version, the CHISG criteria consist of 7 different items. While “core cases” of cervicogenic headache (CEH) usually fulfill all 7 criteria, the IHS classification - 3rd edition beta version- fulfills only 3 criteria. Although the new three beta version represents an improvement from the previous one, it does not quite seem to live up to the expectations for a diagnostic system for routine, clinical use.

Frequency of migraine as a chief complaint in otolaryngology outpatient practice.

Objective. To identify the frequency of typical (headache and dizziness) and common atypical (ear fullness, pressure, pain, tinnitus, facial fullness, and nasal congestion) migraine symptoms as chief complaints among patients presenting to otolaryngology clinic. Methods. This is a descriptive study of prospectively collected data from a general otolaryngology practice. Typical migraine presentations were diagnosed by applying international headache society (IHS) criteria for migraine headache and Neuhauser's criteria for migrainous vertigo. Atypical otologic and rhinologic migraine symptoms were diagnosed using individualized criteria. Charts were reviewed at 6-month interval from the first presentation. Results. Out of 1002 consecutive patients, 10.8% presented with “migrainous chief complaint.” All migrainous chief complaint patients had a history of headache but not all of them presented with headache. Corrected female to male ratio in the migraine group was 3 to 1; age distributions were significantly different between the migraine and nonmigraine groups by applying t-test. Out of the atypical complaints, 86% of the patients had a history of concomitant typical presentation. Conclusion. Actual diagnostic criteria for migraine do not satisfy the diversity of its presentation. Investigating the history of migraine is enough to diagnose most atypical presentations. Sound knowledge about migraine seems essential for any ENT practitioner.

Rhinogenic Headache: The International Classification of Headache Disorders, 3rd Edition

Received March 31, 2014 Accepted July 4, 2014 Address for correspondence Kyung Soo Kim, MD Department of OtorhinolaryngologyHead and Neck Surgery, College of Medicine, Chung-Ang University, 102 Heukseok-ro, Dongjak-gu, Seoul 156-755, Korea Tel +82-2-6299-1765 Fax +82-2-825-1765 E-mail 99-21045@hanmail.net Rhinogenic headache may be defined as a headache directly caused by pathology within the nose or paranasal sinuses. Rhinogenic headache is a controversial, but distinct type of headache that has received an increased amount of attention in the literature over the past twenty years. The International Classification of Headache Disorders, 3rd edition has been released by the ‘International Headache Society’ in May 2013. As this version is based on a large body of research on headache, in contrast to previous editions that were mostly based on opinion of experts, it is being considered as a major step forward in the diagnosis and management of headache. The International Headache Society presented the diagnostic criteria of rhinogenic headache divided into three types: Headache Attributed to Acute Rhinosinusitis, Headache Attributed to Chronic or Recurring Rhinosinusitis, Headache Attributed to Disorder of the Nasal Mucosa, Turbinates or Septum. We herein present the salient features of the new classification, which are likely to be of interest to the rhinologist. In addition, I review the evidence that intranasal mucosal contact points cause facial pain or headache and present the important points to consider in diagnosis and treatment of mucosal contact point headache. Korean J Otorhinolaryngol-Head Neck Surg 2015;58(3):166-72

EHMTI-0152. Epidemiology of primary headaches among adolescents in republic of Croatia

The aim of our research was to perform an epidemiological study of migraine and tension headache among adolescents in Republic of Croatia and to determine whether there are differences in prevalence, socioeconomic status, headache onset, gender distribution, health care utilization and self-medication between these two types of primary headaches. We have surveyed 1876 students attending 18 secondary schools in 10 cities of Croatia using self-administered questionnaire that was designed to classify respondents into a group of migraine or tension headache according to Lipton criteria for migraine and ICHD-2 criteria for both migraine and tension headache. Prevalence of migraine was 12,8% (17% in women and 8,1% in men) and prevalence of tension headache was 38,3% (40,6% in women and 35,7% in men). Prevalence of migraine with TTH was 2,9% (3,1% in women and 2,7% in men). There was significant difference in prevalence of migraine (OR=2,3) and tension headache (OR=1,23) between female and male students. We have found that migraineurs were more prone to self-medication (OR=3,29), as to health care utilization (OR=8,12). Also we have identified smoking as a precipitating factor for migraine. The prevalence of primary headaches in Croatia is similar to that in other countries of the world, tension headache is the most common primary headache, occurring later than migraine, and both types are more common in females. Smoking is a risk factor for developing migraine. Although migraineurs visit the doctor and take medications more frequently, both headaches are underdiagnosed and undertreated. No conflict of interest.