Headache

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

This record is based on the British Association for the Study of Headache (2007) Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache.¹

Some 15% of the UK adult population have migraine, and 80% have episodic tension-type headache from time to time.²
The lifetime prevalence of headache is 96%; higher in women than in men.

Headaches can be primary or secondary.

Primary headache

The two most common are:

• Tension-type headaches (TTH):
  • These are the most common type of headache, with lifetime prevalence ranging between 30% and 78%.^3,4
• Migraine
  • This can occur with or without aura.
  • A typical aura lasts between five 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

• These are unilateral, severe headaches that occur in clusters over six to 12 weeks.
• They are more common in:
  • Men
  • People who smoke
  • Adults older than 20 years
• They tend to occur daily and wake the patient.
• 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).
  • Fewer than 1% of patients who are referred to outpatient clinics have an intracranial lesion.¹
  • 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 over 50 years who has a 'new' headache.
    • Few patients with temporal arteritis have temporal pain, but jaw claudication is virtually diagnostic.¹
    • High dose steroids should be given immediately (do not wait to confirm diagnosis)
    • Immediate review in secondary care, with a view to temporal artery biopsy, should be arranged to confirm the diagnosis.

Timing questions

• Why consulting now?
• How recent in onset?
• How frequent, and what temporal pattern (especially distinguishing between episodic and daily or unremitting)?
• 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 inquire about the others in case they are clinically important

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 is function limited or prevented?
• What medication has been and is used?

State of health between attacks

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

• 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.
• Examine the head and neck for muscle tenderness and stiffness. Limitation in range of movement and crepitation is often revealed, especially in TTH.
• Routine examination of the jaw and bite rarely contribute to diagnosis.
• Some paediatricians recommend that head circumference is 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.
  • The time spent will likely be saved several times over, if it avoids unnecessary future consultations by a still-worried patient.

General measures

Reassurance is part of successful management for most patients with headache.
Take a thorough history and perform a good examination as recommended by the BASH guidelines.¹

Tension type headache

• 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 less than 2 days per week.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy.⁵
  • 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

• Try to identify triggers and advise the patient to avoid them
• Make an acute treatment plan - analgesics with or without antiemetics or triptans
• Consider prophylaxis - initially beta-blockers or amitriptyline

See also our dedicated record on Management of Migraine.

Cluster headache

• Sumatriptan given by subcutaneous injection is the treatment of choice for acute cluster headache. (This is the only formulation of any of the triptans that is licensed for cluster headache.)
• Alcohol should be avoided during a cluster period.
• There is little evidence on prophylactic treatment of cluster headache. Referral to a neurologist or pain clinic is advised.

Medication overuse headache

• Stop the medication causing the overuse headache completely.⁶
• This will initially cause the headaches to worsen; subsequent improvement usually occurs within several weeks, but may take several months.
• There is no evidence 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 6 months.⁵
• If the causative agent is a NSAID, replace it with amitriptyline.
• Referral to a neurologist is advised if management fails in primary care.

• Causing medication overuse headache, by treating chronic headache with regular analgesia rather than suggesting prophylaxis
• Undertreating migraine
• Missing unusual primary headache variants
• Blaming headaches on stress

Refer patients immediately if:

• They have a single sudden severe headache.
• They have progressive headaches.
• They have physical signs.
• You are uncertain of the diagnosis.
• Standard treatments do not work.

• Depression secondary to chronic headache
• Medication overuse headache