The SIGN guideline on the diagnosis and management of headache in adults is a comprehensive resource for GPs, says Dr David PB Watson

Headache accounts for 4.4% of all consultations in primary care;1 this means that every GP in the UK is likely to see a patient with headache at least once a week. Diagnosis involves taking a good history; examination and tests have very little extra to offer.2

In general, GPs are good at taking histories so the diagnosis and management of headache would seem to be well suited to a primary care setting. However, this does not appear to be happening, a recent study has shown that in 70% of cases, adult patients with new-onset headache presenting to their GP were not given a diagnostic label.3 General practitioners find the diagnosis and management of headache difficult and they worry about missing rare, serious causes such as brain tumours;4 however, for every 1000 patients seen in primary care with isolated headache as the only symptom, only one patient will have a primary brain tumour.5

The SIGN guideline on Diagnosis and management of headache in adults has been developed against this background to inform healthcare professionals about the different headache types and to provide practical guidance on their management.2

Headache subtypes

Headache can be classified as either primary or secondary:

  • the primary headaches are not related to any underlying pathology, and include migraine, tension-type headache (TTH), and cluster headache
  • the secondary headache disorders are caused by an underlying pathological condition, and include any head pain of infectious, neoplastic, vascular, or drug-induced origin.6

Chronic headache is defined as headache that occurs on >15 days per month for >3 months.2

There are over 200 types of headache as listed by the International Classification of Headache Disorders (ICHD-II);7 however, the SIGN guideline focuses on the more common primary headache disorders, and on secondary headache caused by medication overuse, as this can make the management of primary headache difficult.2 While the entire guideline is relevant to primary care, this article summarises three key areas for primary care practitioners:

  • the exclusion of secondary headache
  • migraine
  • medication-overuse headache (MOH).

An increased awareness of these areas on the part of the GP, and their implementation, will have the greatest impact on improving patient care and promoting best practice. Although TTH is the commonest type of primary headache, patients rarely present to their GPs with it as it is not disabling. Cluster headache and the other trigeminal autonomic cephalalgias are not discussed in this article because these are rare headaches;2 on an average practice list, for every patient with cluster headache there are 100 patients with migraine.2

Excluding secondary headache

There is no single feature of a patient’s history or examination that can be used to diagnose or exclude secondary headache definitively. The SIGN guideline lists a number of red flag features (see Box 1) that should prompt GPs to consider a secondary cause for their patient’s headache. In patients with primary headache, a neurological examination will be normal other than occasional ptosis during and persisting after an attack of cluster headache. The presence of focal or non-focal symptoms and/or abnormal neurological signs significantly increases the chance of an abnormality and, therefore, secondary headache.

The guideline recommends that patients who present with headache for the first time, or with headache that differs from their usual headache, should have a clinical examination, a neurological examination (including fundoscopy), and blood pressure measurement.2

Box 1: Red flag features for secondary headache2

  • New onset or change in headache in patients who are aged over 50 years
  • Thunderclap: rapid time to peak headache intensity (seconds to 5 minutes)
  • Focal neurological symptoms (e.g. limb weakness, aura <5 minutes or >1 hour)
  • Non-focal neurological symptoms (e.g. cognitive disturbance)
  • Change in headache frequency, characteristics, or associated symptoms
  • Abnormal neurological examination
  • Headache that changes with posture
  • Headache wakening 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 human immunodeficiency infection
  • New onset headache in a patient with a history of cancer
Scottish Intercollegiate Guidelines Network. The diagnosis and management of headache in adults. A national clinical guideline. SIGN 107. Edinburgh: SIGN, 2008. Reproduced with kind permission of the Scottish Intercollegiate Guidelines Network

Migraine

Epidemiology

Migraine is the commonest severe primary headache disorder, affecting approximately 6 million people in the UK in the age range of 16–65 years.8 It can cause significant disability with an estimated 190,000 migraine attacks daily resulting in 25 million days lost from work or school each year.8

Diagnosis

The ICHD-II criteria for migraine without aura are listed in Box 2.7 Any single criterion from the ICHD-II criteria may be missing in up to 40% of patients with migraine,9 with and without aura, but the following should be considered:2

  • approximately 40% of patients report the pain as bilateral
  • 50% of patients describe the pain as non-pulsating9
  • 75% of patients with migraine have neck pain during the migraine attack
  • only 15–33% of patients experience aura.9,10

Up to half of all patients with migraine are misdiagnosed as having a different headache type,2 usually TTH or sinus headache. In one study, in which prospective diary cards were used, 82% of patients diagnosed with episodic TTH, had their diagnosis changed to migraine.11

The use of headache diaries and assessment questionnaires to support the diagnosis and management of headache is recommended by the SIGN guideline.2 Functional impairment, nausea, and sensitivity to light are features of migraine that provide the greatest sensitivity and specificity for diagnosis.12 A diagnosis of migraine should be considered, until proved otherwise, in any patient who presents with a recurrent headache that prevents them from undertaking normal activities.

General practitioners are often unsure whether patients with migraine should have a brain scan. The estimated prevalence for significant intracranial abnormalities in patients with migraine who have a normal neurological examination was 0.2%, as determined by a meta-analysis of neuroimaging studies.13 This prevalence figure is no different to that of scanning a random sample of the population. In patients with a clear history of migraine and a normal neurological examination, without red flag features for potential secondary headache, neuroimaging is not indicated.2

Management
A comprehensive review of migraine management is beyond the scope of this article. However, there are a number of key points that GPs should be aware of:2

  • treatment can be divided into symptomatic acute, or prophylactic therapies
  • acute treatments should be selected for each patient according to the severity and frequency of attacks, other symptoms, patient preference, and previous treatments (e.g. a patient who vomits early in a migraine attack may need a non-oral route for drug administration)
  • a patient who has had little success with simple analgesics may require a triptan
  • a patient’s standard therapy may not give a consistent response and it may be necessary for them to have an alternative treatment available.

Non-pharmacological management should be considered in all patients with migraine. The following interventions may be useful:2

  • patients should be encouraged not to miss meals, although the evidence for specific dietary triggers is poor
  • addressing sleep problems may reduce disability associated with migraine
  • stress management should be considered as part of a combined therapies programme
  • acupuncture should be considered as a preventive measure.

Acute treatment

When initiating acute treatment for migraine, the risks of MOH should be discussed with the patient. Opioid analgesics should not be routinely used for treating migraine because of the potential risk of development of MOH.2 Opioid-containing medications are often purchased directly by the patient from the pharmacist, and some commonly used migraine treatments contain codeine. Many patients are unaware that the overuse of treatments containing codeine can make headache worse.

It is important for GPs to recognise that around 50% of women with migraine report an increase in frequency and severity of migraine attacks around the time of menstruation. Standard acute migraine drugs work for the majority of women. Women who have migraine with aura should not use a combined oral contraceptive pill because of an increased risk of ischaemic stroke.2

Standard first-line acute therapy for migraine is aspirin 900 mg or ibuprofen 400 mg with or without an anti-emetic.2 Oral triptans are recommended if simple analgesics do not provide effective pain relief. They should be taken at, or soon after, the onset of the headache phase of the migraine attack. The response to triptans is idiosyncratic so if one does not work, another should be tried. The SIGN guideline recommends the use of almotriptan 12.5 mg, eletriptan 40–80 mg, or rizatriptan 10 mg.2

Practitioners should be aware that all of the triptans depend on ingestion, except zolmitriptan when used as nasal spray (30% nasally absorbed) and sumatriptan when used as a subcutaneous injection.14

Prophylaxis

The guideline highlights the importance of preventive treatment for migraine sufferers: ‘Preventative pharmacological treatment for migraine should be considered in patients with recurring migraines that significantly interfere with their daily routine, in the presence of contraindication to, failure of, or overuse of acute therapies.’2 Trials demonstrate that prophylaxis provides a reduction in severity and frequency of migraine by 50%.15 The drug treatment recommendations for migraine prophylaxis are as follows:2

  • propranolol 80–240 mg daily as first-line treatment
  • topiramate 50–200 mg daily
  • sodium valproate 800–1500 mg daily
  • amitriptyline 25–150 mg daily
  • venlafaxine 75–150 mg daily.

Pizotifen is a long established prophylactic agent but is of limited value. It is not recommended for routine use.

Box 2: Migraine without aura7

Diagnostic criteria:

A. At least 5 attacks, fulfilling criteria B–D

B. Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated)

C. Headache has at least two of the following characteristics:

1. unilateral location

2. pulsating quality

3. moderate or severe pain intensity

4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)

D. During headache at least one of the following:

1. nausea and/or vomiting

2. photophobia and phonophobia

E. Not attributed to another disorder

International Headache Society. The International Classification of Headache Disorders. 2nd ed. Cephalalgia 2004; 24 (Suppl 1): 8–160. Reproduced with kind permission from Blackwell Publishing.

Medication-overuse headache

Headache that is present for >15 days per month and develops or worsens while the patient is taking regular symptomatic medication is classified as MOH. The ICHD-II criteria for this condition are listed in Box 3. All primary care practitioners should consider the possibility of MOH. Patients who are most at risk are those with migraine, frequent headache, and individuals who are using opioid-based medication, or overusing triptans. Practitioners should also note that patients with a history of migraine who frequently use pain medication for non-headache pain are at an increased risk of developing chronic daily headaches. These patients commonly have other chronic pain disorders such as fibromyalgia and irritable bowel syndrome.16,17 These patients also have a higher incidence of mood disorder, depression, anxiety disorder, and obsessive compulsive disorder.2

Management

The diagnosis of MOH should be discussed in detail with patients so that they understand how their medication has affected their headache. They should be informed that medication withdrawal is likely to initially worsen their headache, but that the situation will improve if they persevere. Patient information leaflets are helpful and the GP should offer follow up and support.

Evidence suggests that the withdrawal headache is shorter for triptan overuse than for opioid overuse and that withdrawal is more likely to be successful in triptan overuse. Simple analgesics and triptans can be stopped abruptly but opioids should be gradually withdrawn. Prophylactic agents tend not to work when medication is overused but may be effective and should be considered when symptomatic medications have been withdrawn.2 It should be noted that there is a high relapse rate: 45% at year 1, with a higher relapse rate for TTH and mixed headache and a lower rate for migraine.2

Box 3: Medication-overuse headache7

Diagnostic criteria:
  • Headache present on ?15 days/month
  • Regular overuse for >3 months of one or more acute/symptomatic treatment drugs:
      • ergotamine, triptans, opioids, or combination analgesic medications on ?10 days/month on a regular basis for >3 months
      • simple analgesics or any combination of ergotamine, triptans, analgesics, or opioids on ?15 days/month on a regular basis for >3 months without overuse of any single class alone
  • Headache has developed or markedly worsened during medication overuse

Implementation in primary care

All GPs should be able to diagnose and manage common primary headaches. Patients should be referred to secondary care if secondary headache is suspected, or if help is required with the management of the rare primary headaches, such as trigeminal autonomic cephalalgias. In reality, only 2–3% of patients presenting with headache are referred—this is lower than expected.2

The SIGN guideline is a comprehensive resource for GPs, and implementation of its recommendations will improve patient care and promote best practice. General practitioners should be encouraged to find time to read the guideline as part of their learning plans. However it will be difficult to ensure that this will happen; headache is not part of the quality and outcomes framework, and there is no financial incentive to manage patients with headache more effectively. Primary care organisations can play their part by encouraging GPs to participate in headache education as part of quality initiatives. Headache services should be urged to include educational information on headache in clinical letters to GPs. The Royal College of General Practitioners could also develop case studies on headache based on the SIGN guideline as part of their eLearning strategy.

In general, patients with headache are rewarding to treat—a few simple interventions can transform a patient’s life very quickly and this is the ultimate incentive for GPs to implement the SIGN guideline.

Click here for CPD questions on this article and the SIGN guideline on the diagnosis and management of headache in adults
  • GPs are often concerned about missing serious underlying disease when patients present with headache
  • With careful assessment, referral for specialist imaging and opinion is rarely necessary in the absence of red flag symptoms and signs
  • Migraine can be managed with simple analgesics, triptans, and prophylaxis
  • PBC consortia should consider the benefit of a specialist headache clinic in primary care
  • Specialist clinics could be staffed by GPwSIs and nurses, and funded by reduced referrals to hospitals
  • Tariff costs general medical outpatient: £189 (new) £91 (follow up)a
  1. Latinovic R, Gulliford M, Ridsdale L. Headache and migraine in primary care: consultation, prescription, and referral rates in a large population. J Neurol Neurosurg Psychiatry 2006; 77 (3): 385–387.
  2. Scottish Intercollegiate Guidelines Network. The diagnosis and management of headache in adults. A national clinical guideline. SIGN 107. Edinburgh: SIGN 2008. Available at: www.sign.ac.uk/guidelines/fulltext/107/index.html
  3. Kernick D, Stapley S, Hamilton W. GPs' classification of headache: is primary headache underdiagnosed? Br J Gen Pract 2008; 58 (547): 102–104.
  4. British Association for the Study of Headache. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache. 3rd ed. Hull: BASH, 2007.
  5. Hamilton W, Kernick D. Clinical features of primary brain tumours: a case-control study using electronic primary care records. Br J Gen Pract 2007; 57 (542): 695–699.
  6. Martin V, Elkind A. Diagnosis and classification of primary headache disorders. In: Standards of care for headache diagnosis and treatment. Chicago, IL: National Headache Foundation 2004. pp.4–18.
  7. International Headache Society. The International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004; 24 (Suppl 1): 8–160.
  8. Steiner T, Scher A, Stewart W et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia 2003; 23 (7): 519–527.
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  10. Smetana G. The diagnostic value of historical features in primary headache syndromes: a comprehensive review. Arch Intern Med 2000; 160 (18): 2729–2737.
  11. Taper S, Dahlof C, Dowson A et al. Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. Headache 2004; 44 (9): 856–864.
  12. Lipton R, Dodick D, Sadovsky R et al. A self-administered screener for migraine in primary care: The ID Migraine Validation Study. Neurology 2003; 61 (3): 375–382.
  13. Morey S. Practice guidelines: Headache Consortium releases guidelines for use of CT or MRI in migraine work-up. Am Fam Physicians 2000; 62 (7): 1699–1701.
  14. British National Formulary. BNF 57. London: Royal Pharmaceutical Society, 2009.
  15. Scottish Intercollegiate Guidelines Network. Diagnosis and management of headache in adults. Quick Reference Guide. SIGN 107. Edinburgh: SIGN, 2008. Available at: www.sign.ac.uk/guidelines/fulltext/107/index.html
  16. Aaron L, Burke M, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000; 160 (2): 221–227.
  17. Nicolodi M, Volpe A, Sicuteri F. Fibromyalgia and headache. Failure of serotonergic analgesia and N-methyl-D-aspartate-mediated neuronal plasticity: their common clues. Cephalalgia 1998; 18 (Suppl 21): 41–44.G