Extended opening and health MOTs top patient wishes
Headache is an area that is often stigmatised and poorly managed. The unmet needs of patients have been brought into sharp focus with new guidelines from the British Assocation for the Study of Headache and the publication of the International Classification of Headache Disorders, both published last year.
Patients invariably think their headache is caused by one of three conditions eye strain, raised blood pressure or a brain tumour. The reality though is that:
·Only around 7 per cent of patients with undiagnosed refractive error have head-ache of which 70 per cent will improve with refractive correction. Because undiagnosed refractive errors are uncommon, only a very small percentage of headaches will be caused by 'eye strain'.
·While rapid increase in BP can cause discomfort in the pain-sensitive cerebral arteries and extravasation of blood into brain tissue can occur in hypertensive encephalopathy, there is no association between headache and mild or moderate hypertension.
·Headache alone is a rare presentation of a brain tumour.
Of the 450 patients we have seen in our Intermediate Care Headache Clinic in Exeter, we have referred 4 per cent onwards to neurologists for further assessment all of whom have been scanned with negative results.
A typical breakdown of headache presentations in general practice, excluding infections, would be:
·40 per cent migraine
·40 per cent tension-type headache
·15 per cent mixed migraine and tension type
·<0.2 per="" cent="" cluster="">0.2>
·<0.05 per="" cent="" serious="" pathology="" ="" tumour,="" vascular="">0.05>
·5 per cent miscellaneous, eg temporal arteritis, neuralgia, pain referred from other structures such as neck or jaw.
Between 20-30 per cent of the above are likely to have an element of medication overuse headache.
GPs should be particularly alert in head-aches that:
·are changing rapidly
·occur after the age of 50
·are precipitated by features suggestive of raised intracranial pressure.
Diagnosis four key questions
Although a basic examination is mandatory (examination of neck, fundi, cranial nerves and blood pressure), an accurate headache history is crucial. This often proves difficult within the constraints of a 10-minute consultation but four key questions are helpful:
As a rule of thumb, migraine sufferers have to lie down, tension-type headache sufferers keep going and the pain of cluster headache is so severe the patient will pace up and down banging their head against the wall.
Migraine and tension-type headache often co-exist which presents diagnostic challenges. Patients will recognise different types of headache that can then be explored individually.
Medication overuse headache is a significant problem and many patients will have already recognised they have a problem.
Progressive symptoms are always a cause for concern and should be explored fully.
Cluster headache is arguably one of the most painful conditions a GP will ever see, invariably misdiagnosed as migraine and usually inadequately treated. The male:female ratio is approximately five:one, unlike migraine where females predominate. Cigarette smoking is said to be almost universal in men with cluster headache and in some cases the heavy use of alcohol.
A cluster headache is a single attack lasting on average 60 minutes whereas a cluster period is an episode during which there are frequent cluster headaches in between which the individual is in remission.
·Sudden onset with rapid escalation
·Unilateral and periorbital
·Lasts 60-90 minutes
·Associated periorbital autonomic feature, such as partial Horner's syndrome, lacrimation, conjunctival injection, nasal stuffiness or rhinorrhoea forehead sweating, facial flushing and oedema are less common
The average cluster period lasts between six and 12 weeks but there is considerable variation between patients and some sufferers develop a chronic form. The gold standard treatment for cluster headache is injectable sumatriptan, but this is not always possible or practical. If the patient only experiences two or three cluster periods a year, then prednisolone 1mg per kilogram reducing over a four-week period can be useful.
For more frequent attacks, oxygen is often helpful, but this must be delivered at a concentration of 100 per cent which is not available with current NHS masks and giving sets. These can be hired from the Cluster Headache Patient Group (www.clusterheadaches.org.uk). For chronic cluster sufferers, verapamil is the drug of choice but it must be used at high doses and titrated upwards carefully, monitoring the ECG for conduction effects. Other options, but less effective, are lithium and topiramate.
Tension-type headache is dull and invariably bilateral with no other associated signs or symptoms. Although it is commonly thought to be due to muscle tension due to disorders of the jaw, neck or underlying anxiety/depression, the true aetiology is unknown.
When associated with migraine, it has been suggested that it is part of a migraine spectrum as it often responds to triptans. Elimination of potential causes in the head and neck and strong reassurance are important factors. The drug of choice is amitriptyline given at the maximum tolerable dose.
Migraine is a severe, pulsatile headache associated with nausea or vomiting. Some important characteristics compared with tension-type headache are shown in box 1.
The key to the acute attack is early treatment and providing patients understand the mechanism of each medication they can tailor their own individual approach. Early treatment is important, first, to overcome the effects of gastric stasis and inhibited drug absorption and, second, to prevent allodynia an increasing anticipation of pain due to a sensitisation of pain centres. If you get an emergency call-out:
·Injectable sumatriptan is the drug of choice but may not be available.
·i.m. diclofenac and anti-emetic is useful.
·Avoid opiates they have a high potential for misuse in this setting.
·Sort out the migraine sufferers should not be having emergency call-outs!
A useful first step is a combination of paracetamol, ibuprofen and domperidone at the earliest onset. These can be bought over the counter. In some cases vomiting can be severe and distressing. Here domperidone suppositories 30mg and diclofenac suppositories 100mg are a valuable option.
Triptans have revolutionised the life of many sufferers. Nasal delivery (sumatriptan and zolmitriptan) can be useful when vomiting is a problem and an injectable formulation (sumatriptan) is now only reserved for the most intractable cases. Wafer formulations (zolmitriptan and rizatriptan) are for convenience only and, contrary to popular belief, are not absorbed through the oral mucosa.
Box 2 shows triptans arranged in two groupings those that have a relatively higher speed of onset and those that have a lower rate of recurrence and fewer side-effects.
A major concern of triptans is the potential for vasoconstriction of the coronary vessels. For this reason, the existence of ischaemic heart disease is an absolute contraindication. Licensing studies have not been undertaken on patients over 65 due to the increased incidence of ischaemic heart disease in this group.
Fortunately the incidence of migraine is significantly lower in the elderly, but in the absence of a relevant history and providing the patient is well-informed, the benefits of using a triptan may outweigh its risk.
There are no specific guidelines as to when prevention should occur. Circumstances that might warrant preventive treatment include:
·Migraine that significantly interferes with a patient's life despite acute treatment
·Failure or side-effects from acute treatment
·Overuse of acute medications
·Very frequent headaches
Preventive medication should be given for at least six weeks at its maximum tolerated dose before its impact should be assessed and if successful continued for at least six months. There is a suggestion that in some cases the migraine mechanism can be 'switched off' so it may be worth tailing off preventive therapy and reassessing the response if the patient is in agreement.
·?-blockers are the drug of first choice propranolol, metoprolol, timolol and nad-olol are licensed for use in migraine. Nebivolol is a useful unlicensed alternative in those who have side-effects from other ?-blockers.
·Amitriptyline is the preventive medication of second choice and particularly useful when there is a co-existing element of tension-type headache.
·The anti-epilepsy drugs form the third-line choices, particularly sodium valproate and topiramate, but migraineurs may have lower tolerance to side-effects than non-sufferers.
·Sanomigran, although widely used and effective in children, is generally ineffective and weight gain can be troublesome. Clonidine is still in use in general practice but has no value in preventive treatment.
·Try to identify a prodrome. This will allow medication, and particularly domperidone, to be administered early in the attack to maximum effect.
·Watch out for aura without headache. This is uncommon but can be quite distressing. Unlike TIA which comes on suddenly, an aura builds up gradually. The preventive treatment of choice is sodium valproate.
·Most patients will have identified triggers for their migraine, but it is important to emphasise that physiology such as levels of hydration and glucose should be kept as constant as possible.
·Watch out for hormone sensitive migraine. Migraine that is particularly worse around the time of menstruation or perimenopausally may have an oestrogen sensitive component which offers additional possibilities for therapeutic manipulation.
Medication overuse headache
Any analgesic medication can be implicated, including the triptans, but codeine and codeine-based compounds tend to be most common. Overuse headache does not occur in patients taking analgesia for pain other than headache.
The underlying mechanisms are not known but psychological factors, neural sensitisation and dysinhibition of pain impulses have been suggested. There are three keys to success:
·A careful explanation to the patient of the nature of the problem.
·Frequent support by the GP during the withdrawal period which must be acute.
·Amitriptyline started in low doses and titrating upwards towards maximum tolerated doses before withdrawal is also a useful adjunct as are oral steroids reducing over a period of four weeks. Use of naproxen or diclofenac may be helpful for transient relief.