GP management of headache
Specialist Dr Leone Risdale answers questions from Dr Sonia Barros D’Sa about one of the most common reasons that patients present to their GP. You can also put your question to Dr Risdale, but be quick. She will answer the first three posted below.
Specialist Dr Leone Risdale answers questions from Dr Sonia Barros D'Sa about one of the most common reasons that patients present to their GP. You can also put your question to Dr Risdale, but be quick. She will answer the first three posted below.
How common is headache?
Headache is the commonest symptom people experience. Each year about 75% of the population experience tension-type headache, and 10% experience migraines. Headache is three times more common in women during their reproductive period. Most people manage their own symptoms, possibly with help from the pharmacy, and only 4% per year consult their doctor. Frequent headache is one of the commonest reasons for sickness absence. Migraine and tension headache are among the top 10 causes of disability throughout the world. So it is definitely worthwhile for GPs to know about the best treatment and advise patients if and when they consult. In fact if GPs were more proactive, some disability might be reduced, and work absence prevented.
When patients present with headache, what are the most common diagnoses?
Migraine without aura is the commonest neurological reason for consulting the GP. Common migraine, as it used to be called, is characterised by recurrent headache attacks lasting four to 72 hours. Typical characteristics are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia. But patients need not experience all these characteristics.
The other common diagnosis is chronic migraine. The term is a bit misleading, as migraine tends to recur over people's lifetime.
But the term chronic migraine is used to describe the frequency of migraine headache which occurs on 15 or more days per month for more than three months. Some 5% of the population suffer from chronic migraine. It has a big effect on patients' work and social life, and may become associated with overuse of rescue medications. Headache clinics see many of these patients.
3How do we diagnose tension headaches?
The pain is usually bilateral, pressing or tightening in quality, and of mild to moderate intensity. It does not worsen with routine physical activity. There is no nausea, but photophobia or phonophobia may be present. Headaches may last from minutes to days. Most people with tension headaches do not consult the doctor.
Tension, migraine and chronic migraine may be on a spectrum, and can be thought of in a similar way to fatigue. The spectrum is from ‘tired all the time' to chronic fatigue to chronic fatigue syndrome. They are portmanteaux terms that describe duration, severity and impact of symptoms. Patients with more chronic physical symptoms (of headache or fatigue) also have more psychological distress, but more of this later.
Any tips when simple analgesia fails for migraine?
First, make sure your patient has tried simple analgesia in the right doses. Most will have. Over-the-counter analgesics for acute pain include aspirin 600-900mg, or ibuprofen 400-600mg early in the attack, buffered soluble or orodispersible formulations, up to four times in 24 hours. If there is nausea, domperidone 10mg up to four times in 24 hours, or prochlorperazine 3-6mg buccal tablets, up to twice in 24 hours.
Step two is to suggest suppositories of domperidone or diclofenac. My experience working in Quebec suggests that Francophones are more likely to accept this than Anglophones, a difference which would make a good PhD project on culture and illness.
Step three is to suggest triptans. Nowadays the new-style pharmacists may suggest this too. Sumatriptan (Imigran Recovery 50mg) is available over the counter. It is important to take this early, to a maximum of 300mg per 24 hours, with an anti-emetic.
If this fails, it is a question of trial and error. The British Association for the Study of Headache (BASH) has made excellent guidelines available on the internet.
Guidelines on headache are currently under development by SIGN, and are due to be published next year.
Is codeine-based treatment contraindicated in view of the risk of developing medication-overuse chronic headache?
Yes. Prevention is better than cure. Repeat prescribing may allow a gradual slide towards analgesic overuse. You should discourage patients from taking opiates and opioids. They increase nausea and have addictive potential. Medication overuse occurs in patients with chronic headache which is present on 15 or more days per month for three months.
In my experience of running a headache clinic, most patients with medication overuse are taking a combination of analgesic drugs on 15 days or more. They are very disabled by their headaches. If they are willing to try complete drug withdrawal, they may need a sick note for the first few weeks.
Often patients cannot achieve withdrawal without other medication to help them cope. Naproxen 250mg tds may help. Some neurologists use prednisolone 60mg per day for two days, 40mg/day for two days, and then 20mg for two days. I prefer to start amitriptyline, 10-75mg at night, and continue it as prophylaxis.
If the headache does not remit in two months, it is not caused by simple analgesic overuse. Patients may have chronic migraine and medication overuse. If this is the case, then amitriptyline should help.
Is migraine prophylaxis more effective than prn management, and what do you suggest?
Rescue and prophylaxis are not mutually exclusive. I see quite a few people in clinic who have one or more headaches per week and are only on rescue medication, but I think at this frequency all patients should be offered prophylaxis and then it is for them to decide. I say my aim in offering prophylaxis is to reduce the frequency and severity of their headaches, and reduce their need for rescue drugs.
The particular first-line drug will depend on co-morbidity and contraindications in the particular patient. I usually explain there are three choices.
• ß-blockers, often used for hypertension. I usually suggest propranolol LA 80 increasing to 160mg per day.
• Amitriptyline, also used for depression and poor sleep. I usually suggest 10mg rising to 50mg per day, and if the patient is also depressed a higher dose will be indicated.
• Anti-epilepsy medications, also used for migraine. I only use valproate or topiramate when ß-blockers and amitriptyline are contraindicated, or fail to help. Sometimes they have gratifying results. When headache has led to chronic disability, both patient and doctor can develop heartsink symptoms. It's so rewarding to see people return smiling.
Patients usually participate in the choice of medication. Afterwards I give them a handout sheet on the drug, as well as a handout on their diagnosis.
Is there a place for alternative, non-drug treatments like cognitive behaviour therapy?
There is an important role for non-drug treatments. Most patients I see have anxieties about what is causing their headaches, including concerns about brain tumours. They also recognise the negative consequences on their family, friends and social life. I have found using a quick CBT approach rewarding. You can ask patients what their ideas are, what other physical symptoms they have, what feelings they have, what they do or do not do when they have headaches, and in what context they occur.
Lee David has written an excellent book, Using CBT in General Practice: the 10 minute consultation (Scion Publishing). I think applying this method helps patients. Some patients need more, and I refer them to a psychologist. He sometimes refers them for autogenic training, which is a relaxation process.
I am currently running a pilot headache school to test a psycho-educational approach. It has been tried by doctors and nurse at Kaiser Permanente in the US with some success. I think it would be a worthwhile activity for UK GPs and nurses with special interest in headache.
GPs are always scared of missing brain tumours. Are there red flags to help distinguish sinister headaches from non-sinister ones?
When I started offering to teach practices to manage headache patients, I found their first priority was spotting sinister causes.
There are warning signs of raised intra-cranial pressure, but they are not usually headache. Probably the symptom most likely to be associated with brain tumour is a new seizure, with or without headache. About 7% of these cases will have a brain tumour. All headaches start off by being new onset, so GPs will be rightly more concerned about new headaches, even if they turn out to be episodic migraine in the long run. Vomiting is clearly a sign that raises concern. Other worrying neurological signs include rash, neck stiffness, drowsiness or confusion, cranial nerve, and motor or sensory signs. These are detailed in the NICE guideline on referral for suspected cancer.
Having said this, less than 0.1% of the lifetime prevalence of headache is associated with brain disease of a life-threatening nature. I find it helps to become confident in fundoscopy. Some 80% of the population have venous pulsations which are visible. Their presence has a high negative predictive value, reducing the probability of raised intracranial pressure. I tell patients I am looking for this, and reassure them when I see venous pulsations. Even when the GP's letter has warned me that the patient wants a scan, I find this is no longer the case by the end of the consultation.
I think doctors need to be confident of their medical and psychological skills to manage headache patients well. Up to a third of patients with headache will have psychological co-morbidity, mostly anxiety, with depression commoner in chronic sufferers. It is important to elicit all the physical and emotional symptoms. GPs have the records and are in the best position to do this. The diagnosis of headache (and epilepsy) is primarily based on the history. GPs should not feel disabled by fears of not remembering neuro-anatomy or how to do a neurological examination. The history is almost everything in the diagnosis.
Online only question
Over the last 25 years GPs have taken on managing hypertension, asthma, diabetes, even depression. Headaches are so common that they currently account for 20-30% of new neurology referrals. If GPSIs see headache patients, neurologists might be able to see and treat the other conditions referred within 18 weeks. I hope that in the 21st century doctors in general practice will give up their fear and avoidance of neurology. Headache management is important, and GPs are the experts.
9Is referring difficult headache patients to a neurologist always the best option?Headache as a condition benefits from a holistic GP approach and it is time general practice took it back. Already about 97% of patients with headache are managed without referral. If more GPSIs are trained, this could rise to 99%. I think they are also more effective than specialists at teaching their colleagues about headache diagnosis and management. It's not rocket science.
Dr Leone Ridsdale is senior lecturer in neurology and reader in general practice at Guy's King's and St Thomas' School of Medicine.
Competing interests None declared
thp headaches what i will do now
Dr Barros D'Sa reflects on the answers to her questions
• Prescribe domperidone/NSAIDs for migraine before moving on to triptans
• Try migraine prophylaxis sooner for patients with frequent migraines
• Avoid prescribing codeine to patients with headaches, and discourage use of over-the-counter preparations containing codeine
• Try amitriptyline to help patients with medication-overuse headache to withdraw from codeine
• Check for signs of raised intracranial pressure in patients presenting with new or worsening headache
• Explore possibilities of CBT for patients who have tension headaches
Dr Sonia Barros D'Sa is a freelance GP in Basingstoke and north Hampshire