Headache in primary care
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| Key Advisers: | Dr Neil Whittaker - GP, Nelson |
| Dr Alistair Dunn - GP, Whangarei | |
| Expert Reviewer: | Dr Alan Wright - Neurologist, Dunedin |
Every headache presentation is unique and challenging, requiring a flexible and individualised approach to headache management.
- Most headaches are benign primary headaches
- A few headaches are secondary to underlying pathology, which may be life threatening
Primary headaches can be difficult to diagnose and manage. People, who experience severe or recurrent primary headache, can be subject to significant social, financial and disability burden.
We cannot cover all the issues associated with headache presentation in primary care; instead, our focus is on assisting clinicians to:
- Recognise presentations of secondary headaches
- Effectively diagnose primary headaches
- Manage primary headaches, in particular tension-type headache, migraine and cluster headache
- Avoid, recognise and manage medication overuse headache
Diagnosis of headache in primary care
The keys to headache diagnosis in primary care are:
- Ensuring occasional presentations of secondary headache do not escape notice
- Differentiating between the causes of primary headache
- Addressing patient concerns about serious pathology
Recognise serious secondary headaches by being alert for red flags and performing fundoscopy
Although primary care clinicians worry about missing serious secondary headaches, most people presenting with secondary headache will have alerting clinical features. These clinical features, red flags, are not highly specific but do alert clinicians to the need for particular care in the history, examination and investigation.
An exception to this may be slow growing intracranial tumours. For this reason fundoscopy, even though positive findings are rare, is essential for every initial headache presentation and periodically thereafter. Slow growing frontal lobe tumours are particularly liable to be silent. They may present with non-specific headache and subtle personality changes, resulting in treatment for depression. In these situations, non-response to treatment may prompt further investigation.
Red Flags in headache presentation Get a PDF of red flags and related tables here
Red Flags in headache presentation include:
Age
- Over 50 years at onset of new headache
- Under 10 years at onset
Characteristics
- First, worst or different from usual headache
- Progressive headache (over weeks)
- Persistent headache precipitated by Valsalva manoeuvre (cough, sneeze, bending or exertion)
- Thunderclap headache (explosive onset)
Additional features
- Atypical or prolonged aura (>1 hour)
- Aura occurring for the first time in woman on combined oral contraceptive
- New onset headache in a patient with a history of cancer or HIV
- Concurrent systemic illness
- Neurological signs
- Seizures
- Symptoms/signs of Giant Cell Arteritis (e.g. jaw claudication)
Causes of secondary headache
The presence of red flags prompts consideration of a wide range of diagnoses. Some of these are listed below.
|
Vascular
Infectious causes
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Tumour Toxins (e.g. carbon monoxide) Giant cell arteritis Hydrocephalus
Metabolic disorders |
Minimal examination for headache presentation
For all initial presentations of headache, examination includes:
- Fundoscopy
- Visual acuity
- Blood pressure measurement
- Examination of the head and neck for muscle tenderness, stiffness, range of movement and crepitation.
The presence of red flags or other features suggesting secondary headache indicate the need for more detailed examination. The question of whether a neurological examination should be performed, and in how much detail, is more problematic when there are no suspicious features and the history is characteristic of a primary headache.
Even when there are no red flags, a brief neurological examination, although unlikely to be positive, is a strong source of reassurance to patients and will save time in future consultations with still-worried patients.
Diagnosis of primary headache
Primary headache is usually caused by tension-type headache, migraine, with or without aura, or cluster headache. Mixed headache types do occur, for example many people experience both migraine and tension-type headaches. Differentiation between the primary headaches is important because there are effective interventions available for each of them.
Headache diaries are useful diagnostic tools, which help the diagnosis of headaches and identification of any predisposing or precipitating factors.
Tension-type headache is the commonest form of primary headache
Most people will have at least one episode of tension-type headache during their lifetime. It is the commonest form of primary headache. The headache is usually described as tightness or pressure, like a tight band, around the head and often spreads to, or appears to arise from, the neck.
Tension-type headache is usually episodic, of low frequency and short duration but chronic tension-type headache can occur on more days than it is absent. Photophobia or exacerbation by movement can occur but these are usually less prominent features than in migraine.
Tension-type headaches are associated with stress and functional or musculoskeletal problems of the neck and often these occur together. Muscles of the head or neck are often tight and tender.
It is often useful to explain to patients that the pain is related to tension in the muscles of the head and neck and is often made worse by stress. This helps exploration of stressors without the patient feeling the clinician thinks ‘it is all in my mind’.
Features of Migraine
Adults with migraine usually have a family history of migraine and experience recurrent episodes of moderate or severe headaches (which may be unilateral and/or pulsating) lasting for several hours or up to 3 days. These are typically associated with gastrointestinal symptoms, limitation of activity and avoidance of light and noise. There is often a preceding aura. People with migraine are free from symptoms between attacks.
When considering a differential diagnosis between migraine and tension headache, the following features are common in migraine but not usually seen in tension headache.
- Aura
- Unilateral headache
- Hypersensitivity, such as to light and noise
- Gastrointestinal symptoms, such as nausea or vomiting
The diagnostic criteria for migraine are reproduced in Table 1. These may be useful in the diagnosis of headache when there is some doubt about the diagnosis, particularly when there is no aura. When migraine is accompanied by aura the diagnosis is easier and only two episodes are required to make the diagnosis.
Table 1: Diagnostic criteria for migraine without aura
Get a PDF of this and related tables here| 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:
|
| D |
During headache at least one of the following:
|
| E | Not attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder). |
| *In children, attacks may be shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent. | |
One third of people with migraine have preceding aura
Approximately one third of people who get migraine, experience preceding aura. Usually auras last for between 5 to 60 minutes before the onset of migraine headache and settle as headache commences. The most frequently reported auras are visual disturbance, such as flickering or jagged lines or blind spots. Visual blurring or spots before the eyes are non-specific symptoms and do not represent aura. Other transient focal neurological symptoms, such as unilateral paraesthesia of a hand, arm or the face, and dysphasia, can also occur as aura in migraine.
Visual or other transient focal neurological signs presenting for the first time in older people always raise the possibility of Transient Ischaemic Attacks (TIAs). Prolonged aura in all age groups, especially continuing after resolution of headache and aura which involve muscular weakness, are indications for specialist investigation to exclude other causes.
Headache in migraine is not always unilateral
Although migraine headache is often unilateral it is not always so and the diagnosis of migraine should not be abandoned when headache is bilateral. The headache of tension-type headache is usually bilateral, but may be unilateral.
Migraine is usually accompanied by hypersensitivity
Hypersensitivity to stimuli, which are not normally noxious, is a common feature of migraine. Photophobia and phonophobia are the most frequently reported but hypersensitivity to touch (allodynia), smell (osmophobia), movement and pulsation of the arteries are also often experienced.
Hypersensitivity in migraine appears to be related to the central sensitisation and resulting peripheral sensitisation that occur in migraine.
Gastrointestinal upsets often prominent in migraine
Visual or other transient focal neurological signs presenting for the first time in older people always raise the possibility of Transient Ischaemic Attacks (TIAs). |
Nausea and vomiting in migraine may be related to vestibular hypersensitivity and can be a prominent disabling feature of migraine episodes. Although anorexia and mild nausea may occur in tension-type headache, it is not usually a major feature.
Features of Cluster Headache
Cluster headache, unlike migraine, affects mostly young men (male:female = 6:1). Typically, the headaches occur in bouts for 6 to 12 weeks, once every year or two. The pain is severe, unilateral and disabling. During bouts, headache usually occurs daily, at a similar time each day.
Associated autonomic features include ipsilateral conjunctival injection, lacrimation, rhinorrhea, nasal congestion and ptosis. These do not always occur but the presence of one or two of these together with a typical cluster headache pattern clinch the diagnosis.
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