Headache, part one: primary headaches

The essentials: 

- Headache is the commonest neurological condition seen by the GP.

- Tension-type, chronic daily headache and migraine are the most prevalent.

- A simple questionnaire can be used to diagnose most headaches.

- Treatment should be tailored to each patient's individual needs.

- Long-term follow-up is essential for optimal management.

1. EPIDEMIOLOGY AND RISK FACTORS

Headache is a common condition that affects most of the population on a more or less regular basis. It can be a primary medical disorder or secondary to other illnesses.

The main primary headaches are, in order of prevalence, tension-type headache, migraine, chronic daily headache, with or without medication overuse headache, and cluster headache (see graph, right).

Tension-type headache

Tension-type headache (TTH) is experienced by over 70 per cent of the general population and can affect men, women and children. The headaches occur at least monthly, and are more common in women than in men. They seem to arise due to the body's response to emotional or physical stimuli such as stress, anxiety, depression, emotional conflicts, anger and fatigue.

Migraine

Migraine attacks usually start in childhood or adolescence and are often associated with the menarche in girls. About 20 per cent of women and 6 per cent of men are affected, giving an overall prevalence of about 13 per cent of people in the UK, highest in young and middle-aged adults.

The two-to-three-times-higher prevalence of migraine in women is in part due to the effect of female sex hormones. Prevalence declines beyond the age of 50.

There is a strong genetic link, and trigger factors (including lifestyle, environmental, internal and possibly dietary factors) are thought to induce attacks in many sufferers. Migraine is also linked to psychiatric disorders, especially major depression.

Chronic daily headache

Chronic daily headache (CDH) is a descriptive term that defines a pattern of headaches that occur on more than 15 days each month for more than four hours on average. Prevalence is about 4 per cent in adults and 1-2 per cent in children, with a female preponderance and no decline with increasing age.

In about half of adult cases (but rarely in children), CDH is associated with the overuse of symptomatic headache medications, and is then known as medication overuse headache (MOH). The main risk factors are a long-term history of TTH or migraine, and the overuse of headache medications.

Cluster headache

Cluster headache is a much rarer condition, but unlike the other headaches is more common in men than in women. The overall prevalence is about 0.4 per cent, with 0.3 per cent of cases in men and 0.1 per cent in women.

Cluster headache tends to start between 20 and 40 years of age, and there is usually no family history.

KEY POINTS

- Headache affects most of the population on a more or less regular basis.

- Migraine affects over one in 10 adults and has a strong genetic component.

- CDH affects about one in 20 adults and is often linked to headache medication overuse.

- Cluster headache is a much rarer condition than the other primary headaches.

2. SYMPTOMS AND THE BURDEN OF ILLNESS

Tension-type headache

TTH is classified as an episodic or chronic headache that lasts from minutes to days, with bilateral, mild-to-moderate pain that is pressing or tightening, and is not exacerbated by physical activity. Photophobia and/or phonophobia, but not nausea, may be present. In many cases TTH does not impact significantly on daily activities.

Migraine

Typical migraine symptoms include a moderate- to-severe headache, which is usually throbbing, unilateral and exacerbated by physical activity, nausea, vomiting, photophobia and phonophobia. Attacks typically occur from one to four times a month, last from four to 72 hours and are separated by pain-free intervals. The attack has different phases of prodrome, aura (infrequently present), headache, resolution and recovery.

The key feature of migraine is its impact on the patient's daily activities. During attacks, the patient suffers from reduced quality of life and finds difficulty continuing employment, household jobs and family and leisure activities or gives them up altogether. This feature is a key aid in diagnosis.

Many patients with migraine do not return to normal between attacks, but remain chronically below par.

Chronic daily headache

Chronic daily headache is an insidious condition that takes several years to develop from an original pattern of episodic headaches.

Patients with migraine as their original headache may have migraine-like daily head-aches, an increase in their migraine frequency or TTH-like daily headaches. However, those with TTH as their primary headache almost always have TTH-like chronic daily headaches.

GPs most often see patients who have a daily or near-daily pattern of TTH-like headaches, with exacerbations of episodic migraine attacks.

Patients are severely affected, with chronic pain, reduced quality of life and emotional disturbances and are challenging to manage.

Cluster headache

Cluster headache is a most painful condition, characterised by intermittent attacks of excruciatingly severe unilateral headache, accompanied by symptoms such as a red eye, tears, nasal congestion or discharge, forehead and facial sweating, pupil constriction, eyelid drooping and oedema and restlessness or agitation.

The headache is typically sudden in onset and cessation, occurs around the eyes, is throbbing or pulsating, and constant or boring in nature. Cluster headaches last for 15-180 minutes (average 45 minutes) and are frequent, ranging from one every other day to eight times daily.

They can be episodic (occurring for weeks or months interspersed with months to years of remission) or chronic, and can be induced by alcohol. Attacks can go on for more than a year, with pain-free remissions of less than 14 days. Most patients have the episodic form.

KEY POINTS

- In TTH, the headaches are mild-to-moderate and do not impact on daily activities.

- In migraine, headaches are episodic, moderate-to-severe and impact severely on daily activities.

- In CDH, headaches occur on most days and have a chronic impact on the patient.

- Cluster headaches are short-lived but severe.

3. SCREENING AND DIAGNOSIS

The high prevalence of headache is not reflected in the number of people who consult with a GP. Even when they do attend, a correct diagnosis is not certain because existing diagnostic criteria are lengthy and may be difficult to interpret.

The Migraine in Primary Care Advisors is a UK group of professionals associated with the management of headache in primary care. They have recently produced a validated diagnostic screen for headache (www.mipca.org.uk/pdf/algorithms/GP_Diagnostic.pdf). Ask additional questions if the diagnosis needs clarification.

Exclude secondary headache

Before using the algorithm, secondary (sinister) headaches should be excluded. Once these have been discounted, the first question to ask is: 'What is the impact of the headache on your daily life?'

If the patient reports that the impact is high, with disruption of employment, household activities or leisure pursuits, then migraine or chronic daily headache should be suspected. If the impact is low, episodic TTH is more likely.

The second question to ask is: 'How many days of headache do you have every month?' If the answer is more than 15 days, chronic headache is more likely, and if it is less, then the patient probably has intermittent migraine.

Patients with migraine should be asked if they experience reversible sensory symptoms associated with their attacks, in order to determine whether they have migraine with or without an aura.

Migraine can be confirmed using a simple three-question screening questionnaire. Patients with two or more of high-impact headache, nausea and photophobia will have migraine.

Short-term or long-lasting?

If a pattern of chronic headaches is established, the physician should investigate whether short-term or long-lasting headaches are the cause.

Cluster headaches can be diagnosed by the characteristic presenting symptom complex already described. The patient with chronic daily headache should be asked about how many days each week they take symptomatic medication. If the answer is more frequently than two days a week, then medication overuse headache should be considered.

KEY POINTS

- Episodic TTH is characterised by episodic low-impact headaches.

- Migraine is characterised by episodic high-impact headaches, with or without aura.

- CDH is characterised by frequent high-impact headaches, in many cases with concomitant overuse of symptomatic medications.

- Cluster headache is diagnosed by its characteristic symptom complex.

4. THERAPEUTIC CHOICES FOR PRIMARY HEADACHE

Many patients with headache tend to be under-treated by physicians, and many sufferers rely on OTC medications. While this may be suitable for treating episodic TTH and some mild migraine attacks, most patients with migraine, and those with CDH and cluster headache deserve appropriate prescription medications.

Episodic TTH is most often self-treated effectively by sufferers with simple analgesics such as aspirin, paracetamol or NSAIDs. Chronic TTH is managed using the treatments that will be described for CDH.

Treatment of migraine

All patients require acute treatments to manage the attacks as they occur. Appropriate treatments include analgesic-based therapies such as paracetamol, aspirin, NSAIDs and analgesic/anti-emetic combinations. These are suitable for mild-to-moderate intensity attacks, with triptans being used for moderate-to-severe attacks.

The aim is to rapidly relieve the headache and other symptoms of migraine and permit a return to normal activities within two hours of treatment. Treatments should be taken as soon as possible for maximum effect (before the headache starts for analgesics, and as early as possible after the headache develops for triptans). Rescue medication should be supplied for when treatment fails.

Sumatriptan 50mg tablets have recently been switched from POM to pharmacy prescription (P) status, although patients need to be carefully screened by the pharmacist before a sale.

Patients with frequent attacks, and those who cannot use, or fail with, appropriate acute medications, may be given preventive medications. The usual first-line treatment is a beta-blocker such as propranolol. The use of pizotifen is well established in the UK but not elsewhere. The antiepileptic drug topiramate has also recently been licensed in the UK.

Research indicates that complementary therapies such as feverfew, butterbur root, magnesium, riboflavin and coenzyme Q may also be effective preventive medications for migraine.Behavioural therapies including relaxation, stress reduction and massage may also prove useful.

The aim of preventive treatment is to reduce attack frequency by 50 per cent. Acute medications are also required for breakthrough attacks.

Chronic daily headache

CDH is treated using a four-point strategy. First, overused symptomatic medications (analgesics, triptans or ergot preparations) are withdrawn, and any withdrawal symptoms treated.

Second, prophylactic medications are introduced to reduce the incidence of the headaches. Amitriptyline and sodium valproate are currently the agents of choice. Alternative serotoninergic and neuromodulator drugs are also used.

Third, limited doses of acute medications are used to treat breakthrough attacks.

Finally, a regime of neck exercises is useful for patients with associated neck stiffness.

Long-term follow-up is required, otherwise patients trend to lapse into their original pattern of chronic headaches.

Cluster headache

Prophylaxis is the mainstay of cluster headache management, initiated at the beginning of a new cluster period. Corticosteroids are best for short-term relief, while verapamil is the gold standard therapy for long-term prophylaxis.

Acute treatments are used as rescue medication when breakthrough attacks occur despite the use of prophylaxis. Subcutaneous sumatriptan 6mg is usually preferred.

KEY POINTS

- The choice of appropriate treatment is governed by the diagnosis.

- TTH sufferers rarely consult and usually self-treat with OTC medications.

- Acute treatments are required for all migraine patients.

- Treatment of chronic headaches is relatively complex.

5. LONG-TERM MANAGEMENT

All types of headache require long-term follow-up to monitor the success of treatment and to prevent relapse.

There are some common principles that can be followed, including regular follow-up appointments, involving the patient in their headache management and using headache diaries, impact questionnaires and other tools for prospective monitoring.

It is best to only switch therapies if existing treatments fail or lead to unacceptable side-effects.

The headache team

Management of headache in primary care is best organised as a team together with other healthcare providers, as illustrated in the flowchart (right).

The GP, practice nurse and ancillary workers provide the core team, sometimes in association with a practice pharmacist.

The practice nurse can conduct initial assessments, providing advice and information and review patients' diaries and other questionnaires during follow-up.

Community pharmacists and nurses, opticians, dentists and complementary practitioners can all direct patients into the core team.

In turn, the GP can refer the patient to a specialist, who may be a consultant neurologist, a headache specialist or a GPSI in headache.

When to refer

The GP who is experienced in headache management should be able to successfully manage patients with most types of headache. However, referral may be necessary when a sinister headache is suspected, or the diagnosis does not clearly identify patients with TTH, migraine, CDH or cluster headache.

Referral is also necessary if the patient is refractory to repeated acute and/or preventive medications, and if the frequency of episodic headaches increases despite intervention.

A GP who is not experienced in headache management may wish to refer all patients who have chronic headaches, because their management is usually difficult.

KEY POINTS

- Prospective long-term care is the key to the success of headache management.

- Use a multidisciplinary team approach to management.

- An experienced GP can manage most types of headache.

- Refer if a secondary cause is suspected.

FURTHER RESOURCES
- Further reading
Dowson A. Your Questions Answered: Migraine and Other Headaches.
Churchill Livingstone.

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