A very persistent headache
JD is 36 and
attends surgery giving a 10-week history
of headaches, felt over the right frontal region and behind the right eye.
These are occurring on a daily basis, feeling quite severe in the mornings
and sometimes waking
her. She has already seen two of your colleagues
and has had her blood pressure checked and
fundi examined. She has been prescribed simple analgesics, which have given only partial relief
for a few hours.
Dr Richard Stokell discusses.
What features might make this a difficult consultation?
The first challenge is to elicit and address this patient's growing concerns and expectations. Two of our most useful tools have already been employed, namely the use of time to clarify diagnosis and reassurance through examination and explanation. A further challenge is to avoid costly, unnecessary and potentially harmful investigations, where you may feel there is very little chance of a positive result. There is a growing perception that your patient wants some answers.
What are the important areas to explore here?
It cannot be assumed that history and examination findings taken previously haven't changed. Site, duration, severity and associated symptoms and another check for neurological signs is worthwhile. It is also worth exploring the effect of these symptoms on the patient's life and psychological symptoms now and prior to the headaches.
Social factors may also be important, such as the threat of redundancy and domestic problems. Look for the patient's interpretation of the symptoms by asking: 'Was there something in particular you were worried about?'
What categories of headache should be considered?
The history here accompanied by normal examination findings does not suggest a space occupying lesion, eye disease, migraine or sinus disease. This points us in the direction of tension-type headache (TTH). Tension headaches have been divided into episodic type, which is often associated with short-term stress and chronic tension headache, which is almost interchangeable with the term chronic daily headache1.
The usual features of chronic tension headache are of a bilateral occipito-frontal site, pressing or tight in nature, often present on waking and sometimes associated with poor concentration and insomnia.
Two variants of this headache worthy of note are analgesic headache and hemicrania continua. Analgesic headache describes the problem of rebound headache after persistent analgesic use and is often seen in patients whose migraine frequency has escalated to daily headaches. This can occur if analgesics are used three or more times a week and is especially common in milder opiod/ paracetamol combinations.
Withdrawal of analgesics is the only real option, although treatment of any associated depression may be of use. Hemicrania continua describes a less common daily headache which is always on the same side, continuous with flare-ups and often accompanied by eye symptoms such as ptosis or conjunctival injection. Indomethacin is thought by some to be particularly effective here.
What are the management options?
At this stage the patient is likely to demand referral or investigation unless attractive management options are offered. The best form of reassurance is by relief of symptoms, even if this is partial or temporary.
Of the drug therapies, non-steroidal anti-inflammatories are most likely to help and
regular dosing with ibuprofen, such as 600mg tds, would be a reasonable option. Also consider treatment of depression if this is uncovered.
Acupuncture would be my next choice of treatment, mainly because it can provide almost instant relief and is now supported by good evidence2. This is especially true where tender trigger zones can be felt in the occipital region and I find short treatments can be managed in normal GP appointments.
Physiotherapy has also been used with success for chronic daily headache.
Should this patient be investigated or referred?
Brain imaging, by CT or MRI scan, is the only investigation likely to be considered. Many GPs are able to order these tests themselves but in some areas this is only possible after neurological referral. Retrospective reviews of patients with chronic headache in the absence of neurological signs suggest a low pick-up rate for significant abnormalities3.
It could be argued a neurology referral would therefore be more appropriate. Unfortunately, it is unlikely they would be any more likely to convince the patient that the investigation was unnecessary and costs would be higher still.
What happens then?
So, your patient has had a persistent headache for several months, has tried various medications and perhaps a physical therapy and now has a normal scan. At this stage we must reconnect with our patient's ideas, concerns and expectations. Have we explored all of these now? 'How do you feel now that you've had the results of your test?' might be a good way to test this.
This may be a good opportunity to isolate the symptom from its emotional component, which is often related to fears of a serious underlying cause such as a brain tumour.
I would be looking for variation in the symptom and trying to relate this to stressful areas of life and hoping to help the patient to recognise these factors. Descriptions of typical days or symptom diaries can help.
lTry to recognise the challenges of a patient attending for the third time with the same problem
lPersistent headaches in young people in the absence of neurological signs are hardly ever a sign of serious intracranial pathology
lIt may be worth learning just a little acupuncture
1 Headache Classification
Sub-Committee of the International Headache Society. The international classification of headache disorders. Cephalgia 2004;
24 (Suppl 1):1-160
2 Acupuncture for chronic headache in primary care, Vickers et al. BMJ-2004
3 Frishberg BM. The utility of neuro-imaging in the evaluation of headache. Neurology 1994
Richard Stokell is a GP in Merseyside