Dr David Kernick provides 10 top tips on the diagnosis and management of headache in primary care
Read this article to learn more about:
- differentiating between the most common types of headache presenting in primary care
- steps to address headache from medication overuse
- when imaging should be used to look for underlying pathology in headaches.
During a 3-month period, 70% of the adult population will experience headache.1 Migraine is the main cause of high impact headache and, according to one study, affects 7.6% of males and 18.3% of females in England.2 Migraine is ranked 6th in the World Health Organization diseases in terms of disability-adjusted life years (a measure of the degree of disability and time spent with it).3 Despite this, the majority of headache sufferers will not seek medical help. When they do, patients are often not taken seriously and less than 30% of patients receive a formal diagnosis.4
Some of the medicines discussed in this article currently do not have UK marketing authorisation for the indications mentioned. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.
1 Take headache seriously
From the patient's perspective, a major factor in the management of headache is a doctor who listens and takes them seriously.
The aims of management should be to allow the patient to:
- understand their condition
- not have any unrealistic hopes of a cure
- be able to take control of their headache rather than their headache controlling their life.
2 Get the diagnosis right
Getting the diagnosis right is important, and, initially, this can be based on asking the patient what they do when they get a headache.
The two major classifications of headache are:
- primary—when there is no identifiable underlying disorder
- secondary—when an underlying cause can be identified.
Box 1 (see below) lists the main subtypes in these groups.
Box 1: Main categories of primary and secondary headache7
Main primary headaches:
- tension-type headache
- cluster headache and other trigeminal autonomic cephalalgias.
Main secondary headaches:
- headache attributed to:
- head and/or neck trauma
- cranial or cervical vascular disorder
- non-vascular intracranial disorder
- a substance or its withdrawal
- disorder of homeostasis
- psychiatric disorder
- headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures
- cranial neuralgias and central causes of facial pain.
Two types of headache form the bulk of consultations for headache in primary care—migraine and tension-type headache4 (the differences between these two types of headache are shown in Table 1, see below). Migraine sufferers will want to lie down, preferably in a quiet, dark room; patients with tensiontype headache will keep going. People with cluster headaches will be agitated and restless.
|Moderate to severe headache||Mild to moderate headache|
|Throbbing/stabbing nature of pain||Pressure or band-like pain|
|Associated symptoms include nausea, vomiting, photophobia, and phonophobia||No associated symptoms|
|Maybe associated with a prodrome or aura||No prodrome or aura|
|Prevents normal activity||Person usually able to continue with normal activities|
History taking and examination
The presence of two out of the following three symptoms has a high sensitivity and specificity for migraine:
- recurrent headaches that interfere with function
- nausea with headache
- light is more irritating with headache than when headache is absent.
A headache diary is often useful, particularly to establish trigger patterns and any association with menstruation in females (see also tip 8).
Physical examination rarely reveals unexpected signs, but is essential to exclude pathology and to reassure the patient. Blood pressure measurement and examination of fundi are minimum requirements at the first consultation. For patients over 50 years of age, an erythrocyte sedimentation rate test is mandatory to exclude temporal arteritis.
3 Exclude medication-overuse headache
Medication-overuse headache affects up to 3% of the adult population5 and can also be a problem in children. It can occur if analgesics are taken on more than 15 days of the month or triptans on 10 days or more of the month over a 3-month or longer period.6 Codeine-containing combination analgesics are most often the cause.7 When headache medication is stopped, patients will experience more severe headaches in the short term and relapse is common—other non-specific symptoms of withdrawal may also occur. There is no evidence base to direct clinical management but abrupt cessation is the best course of action6 after starting preventative medication to treat the underlying headache, which is usually migraine.
4 Treat migraine early
The key to management of an acute migraine attack is early treatment. First, to overcome the effects of gastric stasis and inhibited drug absorption, and, second, the phenomenon of allodynia, which develops with the migraine attack, and which reflects an increasing anticipation of pain due to a central sensitisation of pain centres. This can be achieved by taking a prokinetic as soon as possible, followed by a triptan at the earliest onset of pain.
The addition of a prokinetic drug is important, either metoclopramide or domperidone, which will reduce nausea, increase gastric emptying, and facilitate absorption. An additional approach would be to use a nasal spray or sumatriptan injection if the gastric stasis is significant. It should be noted that melt formulations are for convenience only and are not absorbed through the oral mucosa.
5 Failure of triptans is not a class effect
When treating migraine, the failure of response to triptans is not a class effect, and if one triptan does not work there is an 80% chance that another will. Table 2 (see below)8 lists the available triptans. Triptans work well in combination with paracetamol and there is evidence of a synergistic benefit with naproxen.9
|Higher speed of onset||Longer half-life, fewer side-effects|
|Sumatriptan 50 mg/100 mg||Naratriptan 2.5 mg|
|Rizatriptan 5 mg/10 mg||Frovatriptan 2.5 mg|
|Zolmitriptan 2.5 mg/5 mg|
|Eletriptan 20 mg/40 mg|
|Almotriptan 12.5 mg|
|British Medical Association and Royal Pharmaceutical Society. British National Formulary: Vol. 70. London: BMJ Group and Pharmaceutical Press, 2015.|
6 Look out for cluster headache
Cluster headache is arguably the most painful condition known to medicine, affecting 0.1% of the population annually, with a male:female predominance of 5:1.10 It is often confused with migraine, but a careful history clarifies the diagnosis to an alert practitioner; Table 3 (see below) lists some important differences between migraine and cluster headaches that can assist with this diagnosis. Typically cluster headache manifests for periods lasting 6–8 weeks, two to three times a year, but 10% of people with the condition have the chronic variety, with remission periods of <1 month.10
|Pain can occur in any location||Pain is periorbital|
|Pain is severe and throbbing. Patients want to lie down||Pain is very severe and piercing. Patients pace the room|
|Attack lasts 4–72 hours||Attack lasts 15–180 minutes and headaches come in clusters|
|No autonomic features||Autonomic features around the eye on side of pain|
|Nausea, vomiting, photophobia, or phonophobia||Nausea, vomiting, photophobia, or phonophobia are rare|
For treatment suggestions, refer to NICE Clinical Guideline 150 (CG150).11
7 Always be on the lookout for a serious underlying cause of headache
Serious causes of headache, in particular a brain tumour, are always a concern for the physician and this possibility should always be explored with the patient, who invariably will have similar concerns. However, these are very rare and investigation should not be undertaken only to alleviate anxiety. Taking the time to address the patient's concerns can help avoid unnecessary testing. Worrying features that should alert the GP to a possible secondary cause of headache are:11
- worsening headache with fever
- sudden-onset headache reaching maximum intensity within 5 minutes
- new-onset neurological deficit
- new-onset cognitive dysfunction
- change in personality
- impaired level of consciousness
- recent (typically within the past 3 months) head trauma
- headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
- headache triggered by exercise
- orthostatic headache (headache that changes with posture)
- symptoms suggestive of giant cell arteritis
- symptoms and signs of acute narrow-angle glaucoma
- a substantial change in the characteristic of the headache.
Investigation should not be undertaken for reassurance only. The anxiety and insurance implications caused by incidental abnormalities (found in 10% of GP referrals for computed tomography12) should not be overlooked. Box 2 (see below) summarises some important adult tumour risks.
Box 2: Some tumour risks in adults to bear in mind
- Annual incidence in population: 6–10 per 100,000
- Headache presentation to GP: 1 in 1000
- Headache presentation to GP if migraine or tension-type headache can be diagnosed: 1 in 2000
- Risk of tumour in isolated headache where diagnosis cannot be made after 8 weeks: approx 8 in 1000
- Risk of discovering incidental abnormality on GP investigation: 10 in 100
- Suggested risk of tumour at which investigation should take place: 1 in 100
- Risk of secondary brain cancer with primary elsewhere: 20–40%
8 Be aware of a menstrual relationship with migraine
Of women experiencing migraine, up to 14% will have migraine exclusively when menstruating, although over one half will report that headaches are more likely in association with their period.13 Menstrual migraine usually occurs on day 1 (± 2) of menstruation and the association is stronger for migraine without aura than for migraine with aura. It is thought to result from falling oestrogen levels.
Menstrual migraine should be treated as for normal migraine; however, specific treatment can be helpful and options are:
- prophylactic anti-inflammatory tablets 24 hours before anticipated onset of attack—naproxen is the drug of choice, or mefenamic acid if there is concurrent dysmenorrhoea
- tricycling the pill (taking three packets in succession without a pill-free interval) if on oral contraception, in the absence of migraine with aura—this prevents any reduction in oestrogen levels
- a transdermal 100 µg oestrogen patch 48 hours prior to menstruation, repeated after 3 days for a total of two applications. Alternatively, oestradiol gel can be applied daily, which gives more stable levels
- small doses of prophylactic triptans. The treatment of choice is frovatriptan, which has a long half-life; for example, half a tablet a day commencing 24 hours before the expected onset of attack14
- injected medroxyprogesterone inhibits ovulation and can help in some cases. The progestogen-only pill is usually not effective.
9 Be aware of a patient’s quality of life and functioning when prescribing preventative therapy for migraine
There are no specific indications for using preventative treatment in migraine, and the impact of attacks on the patient's quality of life is the best guide. Beta-blockers (propranolol), topiramate, and amitriptyline are drugs of first choice for prophylactic treatment.11 Medication should be taken for at least 8 weeks before benefit can be assessed.14
Alternative non-drug therapies include behavioural and physical therapies such as biofeedback, relaxation therapy, cervical manipulation, and cranial massage, but there is no supportive evidence base. NICE CG150 on Headaches in over 12s: diagnosis and management indicates that acupuncture may be considered, and it notes some supportive evidence for a daily dose of riboflavin.11
10 Bear in mind that children can have migraine too
Migraine is the most common type of headache in children and is often overlooked. It has a peak incidence at the age of 15 years in females and 10 years in males.15 If a parent has migraine, there is an 80% chance the child will be affected. A large UK school clinical study reported an annual prevalence rate of 10.6%.16 Table 4 (see below) lists the important features of migraine in adults and children.
|Migraine in adults||Migraine in children|
|Usually unilateral||Usually bilateral|
|Moderate to severe headache||Mild to severe headache. May be inferred from behaviour in younger children|
|Throbbing/stabbing nature of pain||Pain can take any form|
|Lasts for 4–72 hours||Usually lasts for less than 4 hours|
|Associated symptoms include nausea, vomiting, photophobia, or phonophobia||Associated symptoms are not always present|
|Can be associated with an aura in 30%||Aura less common|
|Frequently prevents normal activity||Frequently prevents normal activity|
The British Association for the Study of Headache for UK headache management guidelines Exeter Headache Clinic has clinical guidelines for the management of headache and comprehensive patient information treatment sheets that can be downloaded. Useful information can also be obtained from patient support groups:
- Rasmussen K, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population—a prevalence study. J Clin Epidemiol 1991; 44 (11): 1147–1157.
- 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.
- World Health Organization. Headache disorders. Fact sheet, updated April 2016. Available at: www.who.int/mediacentre/factsheets/fs277/en/ (accessed 12 July 2016).
- Kernick D, Stapley S, Hamilton W. GPs' classification of headache: is primary headache underdiagnosed? Br J Gen Pract 2008; 58 (547): 102–104.
- Diener H and Limmroth V. Medicationoveruse headache: a worldwide problem. Lancet Neurol 2004; 3 (8): 475–483.
- NICE. Headache—medication overuse. Clinical Knowledge Summary. NICE, 2012. Available at: cks.nice.org.uk/headache-medication-overuse (accessed 14 July 2016).
- Olesen J, Bousser M-G, Diener H-C et al for the Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders, 2nd edition. Cephalalgia 2004; 24 (suppl 1): 1–151.
- British Medical Association and Royal Pharmaceuitcal Society. British National Formulary: Vol. 70. London: BMJ Group and Pharmaceutical Press, 2015.
- Brandes J, Kudrow D, Stark S et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA 2007; 297 (13): 1443–1454.
- Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: a meta-analysis of populationbased studies. Cephalalgia 2008; 28 (6): 614–618.
- NICE. Headaches in over 12s: diagnosis and management. Clinical Guideline 150. NICE, 2012. Available at: www.nice.org.uk/guidance/cg150 (accessed 14 July 2016).
- Thomas R, Cook A, Main G, et al. Primary care access to computed tomography for chronic headache. Br J Gen Pract 2010; 60 (575): 426–430.
- Reid R, Case A. Premenstrual Syndrome and menstrual related disorders. In: Falcone T, Hurd W, editors. Clinical reproductive medicine and surgery. Elsevier Health Sciences, 2007: 343.
- Scottish Intercollegiate Guidelines Network. Diagnosis and management of headache in adults. SIGN 107. Edinburgh: SIGN, 2008. Available at: www.sign.ac.uk/guidelines/fulltext/107
- Abu-Arefeh I, Russell G. Prevalence of headache and migraine in school children. BMJ 1994; 309: 765–769.
- Stewart W, Linet M, Celentano D et al. Age-and sex-specific incidence rates of migraine with and without visual aura. Am J Epidemiol 1991; 134 (10): 1111–1120. G