Patient presents with a complaint of headache.  The onset, duration, character, and location of the headache are not clearly defined or consistent with a specific headache diagnosis.  Patient describes the headache as generalized or non-specific. Associated symptoms, if present, are vague and do not meet the criteria for migraine, tension-type headache, cluster headache, or other classified headache disorders.  A thorough neurological examination reveals no focal neurological deficits.  Review of systems is negative for red flag symptoms such as fever, stiff neck, vision changes, or recent head trauma.  Differential diagnosis includes tension-type headache, migraine without aura, and primary headache NOS.  Due to the lack of specific characteristics, the diagnosis of headache, unspecified (ICD-10 code R51) is made.  The patient was educated on headache triggers, lifestyle modifications, and over-the-counter pain management strategies such as ibuprofen or acetaminophen.  Follow-up is recommended if symptoms worsen or change significantly, or if specific characteristics emerge suggesting a more defined headache syndrome. The patient was advised to return for further evaluation if symptoms persist or if red flags develop. Medical billing codes will reflect evaluation and management services provided. This documentation supports the diagnosis of unspecified headache and outlines the plan of care.