[When to suspect secondary headache? Headache management in general internal medicine]

Headaches, mostly primary, are common in general practice. However, there may be secondary causes, although their incidence is relatively low. These include otolaryngologic and upper airway infections, cervical spine or tensional abnormalities, as well as vascular or intracranial pathologies. Based on a headache case, this article illustrates the clinical reasoning for managing headaches in the outpatient setting. The patient had an unusual Valsalva-related headache with normal vital and neurological parameters, but investigations revealed retropharyngeal emphysema and pneumomediastinum. This case highlights the importance of the primary care physician, who should take a detailed anamnesis and perform a complete clinical examination to identify signs of severity and, thereby, determine the need for specific investigations.