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How to conduct an effective headache consultation

In the first of a five-part series on headache, GPs Dr David Kernick and Dr John Fox look at the key elements of a successful consultation

In the first of a five-part series on headache, GPs Dr David Kernick and Dr John Fox look at the key elements of a successful consultation

In the UK, 3% of GP consultations are for headache, of which 4% are referred to secondary care. Migraine is the most common diagnosis.

For primary headaches, cure is rarely possible. The aim is to change the locus of control from a situation where the headache has control over the patient to one where the patient has an understanding of and control over their problem.

Effective physician-patient communication improves outcomes. As the headache presentation has physiological, motivational, affective and cognitive components, optimum management is likely to include a number of dimensions that include pharmaceutical, social, psychological and behavioural factors.

41216202The box on consultation points here offers some factors that can facilitate the process and improve outcomes.

Taking a history

The history is the most important diagnostic tool, as the examination will usually be normal. It is important to ascertain the following.

Types of headache

Often patients will recognise more than one type of headache, and this can cause diagnostic confusion if these are not considered individually. Clinically it is most rewarding to focus on the type that gives most distress, at least in the first encounter.

Circumstances and age of onset

• Migraine invariably starts in childhood or early adult life.

• Migraine and cluster headache can be triggered by head trauma.

• Peripartum period – cortical vein or sagittal sinus thrombosis.

• New presentation over the age of 50 more frequently has an underlying cause – temporal arteritis is the most common.

Location and radiation

• Migraine is usually unilateral. Cluster is almost always unilateral.

• Tension headache is usually bilateral.

• Focal pain alerts to the possibility of local pathology.

Severity and quality

• Patients can describe pain on a scale from 0 (no pain) to 10 (the worse pain imaginable). This can be useful for diagnosis and monitoring of treatment.

• The pain of cluster headache is excruciating – often described as if a red hot poker is being driven into the eye.

• Migraine is very often described as throbbing or pulsatile.

• Brain tumour and meningitis are usually constant.

• Tension type is dull, nagging and persistent ‘like a band'.

• An acute ‘thunder clap headache'

(TCH) can be caused by subarachnoid haemorrhage (SAH).

Associated features

• Premonitory symptoms and aura occur in migraine.

• Photophobia, phonophobia and movement sensitivity are features of migraine

• Autonomic features occur periorbitally in cluster headache.

• Gastrointestinal disturbances are most commonly associated with migraine but can occur with any headache.

Precipitating or exacerbating factors

• Onset with exertion – SAH or benign exertional headache.

• Hormone changes – pregnancy, menstruation, perimenopause and combined oral contraception – these particularly affect migraine.

• Lifestyle or environmental changes – stress, too much sleep, missing a meal, weather changes – these are common migraine triggers.

• Substance triggers.

• Stimulation of trigger points on face and mouth such as exposure to cold air or brushing teeth can provoke trigeminal neuralgia.

• Changes in body position can intensify headache associated with nasal disease or CSF pressure.

• Worse with coughing, sneezing on wakening – abnormalities of CSF pressure.

Relieving factors

• Lying in a dark room helps to relieve migraine.

• Pressure on trigger points can help migraine.

• Vigorous movement, sitting upright or rocking can relieve cluster.

• Tension type can be relieved by relaxation and rest or exercise.

Social and employment history

• Stressful life events can have a significant role in headache.

• Alcohol, smoking, drugs or sexual activity may be relevant.

• Heating at home, other family members – remember the possibility of carbon monoxide poisoning.

• Explore potential work-related exposure to drugs or toxins.

Sleep habits

• Sleep apnoea can cause morning headache.

• Hypnic headache typically wakes the patient.

Family history

About 60% of migraine sufferers have a parent and 80% a first-degree relative who gets migraines. This is a useful clue to support diagnosis.

Medication and past headache history

• Treatment response can support a diagnosis.

• Often previous treatment failure is a result of inadequate dosing or continuation of drug.

• Medication overuse headache may be a problem, particularly with OTC medication.

• Many patients will have tried complementary therapies.

Medical history

• Comorbidity, particularly tumour, can present as headache.

• Depression and anxiety are comorbid with migraine and can be a cause of tension-type headache.

• Comorbidity may direct treatment options, particularly depression, asthma, hypertension and epilepsy.

Framing the question

• Answers may be influenced by preconceived notions.

• Be aware of non-verbal clues.

• Put questions in an experiential format. For example, not ‘does noise bother you?' but ‘do you have to turn down the TV during an attack?'

• Treat a questionnaire diagnosis with caution.

Examination

41216201

• The examination rarely adds to the diagnosis, but an underlying cause must always be excluded.

• A full neurological examination is rarely possible within the constraints of the consultation in primary care.

• Fundoscopy and blood pressure measurement are minimum requirements. However it is worth noting that, with the exception of malignant hypertension, the relationship between blood pressure and headache is contested.

• A simple proforma that would exclude most pathologies is suggested in the box above right.

Formulating a management plan

• Take patients' preferences into account.

• Provide supportive literature particularly for any drugs prescribed.

• Discuss implications for using unlicensed drugs.

Dr David Kernick is a GP in Exeter, chair of the British Association for the Study of Headache and runs an intermediate care headache clinic

Dr John Fox is a GP with a special interest in headache and works in Exeter

This is an extract from Headache: A Practical Manual, by Dr David Kernick and Dr Peter Goadsby, published by Oxford University Press, ISBN 978-0-19-923259-8. It is a handbook aimed at all healthcare professionals dealing with patients with headache. Available from bookshops or direct from Oxford University Press

Exam Consultation Pupillary responses and fundoscopy should be part of the exam Pupillary responses and fundoscopy should be part of the exam Headache Impact Test - HIT6 Headache Impact Test

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