This is one of the most common reasons for attending a general practice surgery or a neurology clinic.

Epidemiology

Headache affects everyone at some time. Some 15% of the UK adult population have migraine, and 80% have episodic tension-type headache from time to time.^1,2

The lifetime prevalence of headache is 96%; higher in women than in men.

Classification

Headache can be classified as either primary headache or secondary headache.²

Primary headache

The two most common are:

• Tension-type headache (TTH) - see separate Tension-type Headache article:
  • These are the most common type of headache, with lifetime prevalence ranging between 30% and 78%.^3,4
  • Characteristics of TTH are that they are bilateral, pressing or tightening in quality, mild-to-moderate in intensity with no nausea. They are not aggravated by physical activity. There may be pericranial tenderness and sensitivity to light or noise.⁵
• Migraine:⁶
  • This can occur with or without aura.
  • A typical aura lasts between 5 to 60 minutes, usually before the headache starts.
  • It may consist of transient visual, sensory, and speech disturbances.
  • Visual symptoms are the most common manifestation of an aura and consist of flickering lights, spots or zig-zag lines, fortification spectra or blind spots.

Cluster headaches occur less commonly, with a prevalence of 69/100,000;^3,4 they are characterised by attacks of severe unilateral pain in a trigeminal distribution. They are more common in:

• Men.
• People who smoke.
• Adults older than age 20 years.

They tend to occur daily and wake the patient, as the pain of cluster headaches is severe. They are associated with ipsilateral watering of the eye, conjunctival redness, rhinorrhoea, nasal blockage and ptosis.

Secondary headaches

These include:

• 'Not immediately life-threatening' headaches:
  • Secondary to a substance, or its withdrawal, e.g. carbon monoxide, alcohol, medication overuse.
  • Secondary to trauma or the structure of the head and neck, e.g. sinusitis, glaucoma.
  • Secondary to psychiatric problems.
• Dangerous headaches:
  • These represent a small proportion of patients. Causes may include:
    • Subarachnoid haemorrhage, meningitis, temporal arteritis, and raised intracranial pressure (of whatever cause).
    • Less than 1% of patients who are referred to outpatient clinics have an intracranial lesion.²
    • Dangerous headaches tend to be 'first and worst'. They occur suddenly, and are progressive with onset usually later in life.
    • Consider temporal arteritis in any patient aged over 50 years who has a 'new' headache. Few patients with temporal arteritis have temporal pain, but jaw claudication is virtually diagnostic.²

History²

How many different headache types does the patient experience?

• Separate histories are necessary for each.
• It is reasonable to concentrate on the most bothersome to the patient, but always enquire about the others in case they are clinically important.

Timing questions

• Why consulting now?
• How recent in onset?
• How frequent, and what temporal pattern (especially distinguishing between episodic and daily or unremitting)?
• How long do they last?

Character questions

• Intensity of pain.
• Nature and quality of pain.
• Site and spread of pain.
• Associated symptoms.

Cause questions

• Predisposing or trigger factors.
• Aggravating or relieving factors.
• Family history of similar headache.

Response questions

• What does the patient do during the headache?
• How much are activities limited or prevented?
• What medication has been tried and how is it used?

State of health between attacks

• Completely well, or any residual or persisting symptoms?
• Concerns, anxieties, fears about recurrent attacks or their cause?

Examination

The time spent will likely be saved several times over, if it avoids unnecessary future consultations by a still-worried patient.

• The optic fundi should always be examined during the diagnostic consultation.
• Blood pressure measurement is recommended:
  • Raised blood pressure is very rarely a cause of headache, but patients often think it may be.
  • Raised blood pressure may make headache of other causes, including migraine, more difficult to treat unless itself treated.
  • Drugs used for headache treatment can affect blood pressure.
• Palpate the temporal arteries if the patient is over 50 years of age.
• Examine the head and neck for muscle tenderness and stiffness. Limitation in range of movement and crepitation are often revealed, especially in tension-type headache (TTH).
• Routine examinations of the jaw and bite rarely contribute to diagnosis.
• Some paediatricians recommend that head circumference be measured at the diagnostic visit, and plotted on a centile chart.
• The physical examination adds to the reassurance of the patient. The more thorough the examination, the better - within reason.

Management

General measures

Reassurance is part of successful management for most patients with headache.

Tension-type headache (TTH)

See separate Tension-type Headache article.

• Manage any concomitant anxiety or depression.
• Suggest physical exercise.
• Recognise that patients may have more than one type of headache.
• Symptomatic medication may be appropriate if the headache occurs on average fewer than two days per week.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy.⁷
  • Paracetamol is recommended for people intolerant of NSAIDs.
  • Opioids (including codeine) must be avoided due to the risk of developing medication-overuse headache; the risk is much higher with opioids than with NSAIDs or paracetamol.
  • Remember to ask about over-the-counter medications, as many contain codeine.

Migraine

See separate article Migraine Management.

Cluster headache

See separate article Cluster Headache.

Medication-overuse headache

• Stop the medication causing the overuse headache completely.⁸
• This will initially cause the headaches to worsen; subsequent improvement usually occurs within several weeks, but may take several months.
• There is no evidence on whether to advise abrupt or gradual withdrawal of the drug.
• Replace the causative medication with a regular NSAID (any), and continue until the headache improves. This may be up to six months.⁹
• If the causative agent is an NSAID, replace it with amitriptyline.
• Referral to a neurologist is advised if management fails in primary care.

When to refer

Red flag features which should prompt referral for further investigation:⁵

• New onset of, or change in, headache in patients who are aged over 50 years.
• Thunderclap: rapid time to peak headache intensity (seconds to 5 minutes) - same-day specialist assessment required.
• Focal neurological symptoms (e.g. limb weakness, aura <5 minutes or >1 hour).
• Nonfocal neurological symptoms (e.g. cognitive disturbance).
• Change in headache frequency, characteristics or associated symptoms.
• Abnormal neurological examination.
• Headache that changes with posture.
• Headache waking the patient up (NB: migraine is the most frequent cause of morning headache).
• Headache precipitated by physical exertion or Valsalva manoeuvre (e.g. coughing, laughing, straining).
• Patients with risk factors for cerebral venous sinus thrombosis.
• Jaw claudication or visual disturbance.
• Neck stiffness.
• Fever.
• New-onset headache in a patient with a history of HIV infection.
• New-onset headache in a patient with a history of cancer.

Complications

• Depression secondary to chronic headache.
• Medication-overuse headache.

Document references

1. Fuller G, Kaye C; Headaches. BMJ. 2007 Feb 3;334(7587):254-6.
2. Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache, British Association for the Study of Headache - BASH (2010)
3. Silberstein, S.D., Lipton, R.B. and Goadsby, P.J. (2002) Headache in clinical practice. 2nd edn. London: Martin Dunitz.
4. Rasmussen BK, Jensen R, Schroll M, et al; Epidemiology of headache in a general population--a prevalence study.; J Clin Epidemiol. 1991;44(11):1147-57. [abstract]
5. Diagnosis and management of headache in adults, Scottish Intercollegiate Guidelines Network - SIGN (November 2008)
6. Migraine, Prodigy (October 2010)
7. Headache - tension-type, Prodigy (August 2009); (minor update 2011)
8. Zed PJ, Loewen PS, Robinson G; Medication-induced headache: overview and systematic review of therapeutic approaches. Ann Pharmacother. 1999 Jan;33(1):61-72. [abstract]
9. Headache - medication overuse, Prodigy (August 2009)