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Patient worried her headache is a brain tumour

Dr Tanvir Jamil discusses consultation and management

Dr Tanvir Jamil discusses consultation and management

Case history

Christine has had a headache for more than a month. She has a slightly muzzy head and neck ache but feels otherwise well. She makes an appointment to see you because she almost never gets headaches. She has had a bit of stress at work from covering a colleague who recently died from a brain tumour.

Headache is probably the most common presenting symptom in general practice. Are there any facts or figures to back this up?

  • 90 per cent of all people have a headache in a given year
  • Over any two-week period, 25 per cent of people will have a headache severe enough to take analgesia
  • A telephone survey in the USA revealed that 5 per cent of women and almost 3 per cent men had more than 180 headaches per year

What kinds of headaches are mainly diagnosed in the GP setting?

  • 40 per cent tension (or 'muscular contraction')
  • 30 per cent migraine
  • 30 per cent other
  • 20 per cent referred to secondary care

How can we safely diagnose tension headaches?

Tension headaches are five times as common as migraines. Also called muscular contraction headaches, typical features include long history (often many months), tightness around the head ('like a vice' or 'tight band'), bifrontal (occasionally occipital) often associated with neck pain or ache and spasm in the trapezius muscles.

Many sufferers also have associated anxiety, stress or depression. The headaches seem to worsen towards evening. Examination usually reveals nothing remarkable although many patients are reassured by normal examination findings, especially blood pressure.

What are the options for treatment of tension headaches?

Reassurance and simple analgesia may be all that is required. Often patients do not take the full dose of painkillers and simple instructions on dosing and combinations of paracetamol and ibuprofen will help. A good trick is to advise patients to take two paracetamols four times daily for one week – whether they have the headache or not.

After seven days they should reduce the dose of paracetamol by two tablets a day and eventually stop. Keeping the headache away in this fashion often relieves the patient, eases any muscle tension in the neck and can stop the headaches recurring.

Low-dose amitriptyline is also effective against tension headaches. Start off with 10mg nocte and build up to 50-100mg if required. Increasing exercise levels may also help, as will practising relaxation techniques (such as yoga, tai chi, meditation) and neck exercises. Acupuncture can help but is more effective for migraines than tension headaches.

Christine is clearly worried about the possibility of a brain tumour. How many are actually diagnosed?

Headache makes up almost a quarter of neurology referrals:

  • 70 per cent benign diagnosis
  • 3 per cent brain tumour
  • 5 per cent other serious causes
  • 22 per cent no diagnosis made

What red flags do you look for in a patient with a chronic headache?

  • Headache present on waking
  • Pain increase with manoeuvres that raise intracranial pressure (ICP)
  • Any associated neurological symptoms or signs
  • If the character of the headache did not suggest migraine or tension headache

The headache of raised ICP is worse when the patient wakes up – typically as soon as they open their eyes. Occasionally the headaches are severe enough to awaken the patient from sleep.

Lying flat increases cerebral oedema, which in turn increases ICP and the headaches. As the patient moves around the swelling subsides as does the headache. Headaches worsen when the patient strains (such as coughing, sneezing or opening bowels) or on bending and stooping.

Patients with cerebral tumours are not usually photophobic and, surprisingly, simple analgesia often helps their headache during the initial phase. Eventually the severity of the headaches increase and may be associated with nausea and vomiting.

Examination may reveal papilloedema. The latter, however, may not develop in some people and in others – especially long-sighted individuals – may be wrongly diagnosed. Other neurological signs to look for include visual field defects, minor degrees of imbalance, clumsiness, asymmetrical weakness and difference in reflexes.

Meningitis typically causes a throbbing headache often accompanied by fever, photophobia, neck stiffness and occasionally rash. Encephalitis also causes headache in the presence of cerebral dysfunction such as disorientation and confusion.

Subarachnoid haemorrhage (SAH) has an incidence of one in 10,000 and accounts for about 6 per cent of cerebrovascular disease. Typically patients are over 40 and describe the headache as 'the worst I have ever had' and like 'being hit on the back of the head with a hammer'. Almost half the patients have had a 'warning leak' in the month before the SAH but most of these are overlooked by both the patient and doctor.

Symptoms and signs include headache, loss of consciousness, nausea, vomiting, convulsions, meningism, focal signs (such as limb weakness or dysphasia) and delay in diagnosis or treatment can sometimes result in death – such as aneurysmal rebleeding.

Temporal arteritis is a chronic vascular disease that occurs in the elderly and is associated with polymyalgia rheumatica. Symptoms include headache, jaw claudication and scalp tenderness around the temporal area. A tender cranial artery may also be palpated. ESR is often raised at over 50mm/hr but a clinical suspicion with a normal ESR still warrants treatment with high dose steroids – up to 80 mg prednisolone. The most serious complication of temporal arteritis is blindness from involvement of the retinal artery.

When should I consider a neurological referral?

Clearly if any of the suspicious signs and symptoms mentioned above are found the patient should be referred immediately. If there is anything odd about the character of the headache that does not fit in with a 'normal pattern' you should keep them under regular review and, if things do not improve, consider referral.

Many will have had their headache for many months – effectively excluding a serious cause – but some will still need referral for reassurance. A full history and examination for all patients with headaches is essential – this will ensure you pick up most of the rare serious causes and go a long way to reassure the patients that they are being taken seriously. Often patients just need reassurance that their headaches are 'not a brain tumour'.

Dr Tanvir Jamil is a GP and trainer in Burnham, Buckinghamshire

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