How to consult remotely: headache

GP specialist Dr David Kernick explains the fundamentals of remote consulting for headache

Headache is a clinical area that lends itself well to remote consultation. Having worked for more than 20 years in a headache clinic, I cannot recall a single case when I have changed my management because of the clinical examination. An accurate history is paramount; otherwise the essentials of good care are:

• Blood pressure (to exclude malignant hypertension) and fundoscopy at presentation. 
• Inflammatory markers for those over 50 to assess for temporal arteritis. 

These are things that can now be dealt with remotely: many people now have access to home blood pressure monitoring and although fundoscopy must be a part of the GP’s repertoire, very accurate assessments can be made by the optician. Furthermore, evidence suggests that headache consultations have similar outcomes whether they are face to face or remote.^1,2

Therefore, while surveys suggest that a third of patients still prefer face-to-face consultations,³ GPs can be confident of managing the initial process over the phone or by video, for those patients happy to consult remotely. 

However, as presentations become more complex, particularly with chronic migraine which can be associated with a number of comorbidities, face-to-face consultations are preferable for identifying important subtle clues and enhancing information gathering and communication.

The three aims of headache management are: exclude headaches that need immediate attention; identify those that need urgent investigation; and diagnose and treat primary headache. 

Key pointers in the history

• Why is the patient consulting now? What are their underlying concerns? Although an underlying brain tumour is rare, it is invariably a concern for both patient and practitioner.
• How many types of headache does the patient have? Often people will present with a number of different types. If one type is migraine, the others are likely to be part of a migraine spectrum.
• Is the headache progressive? Headache that is getting worse raises the suspicion of a serious underlying pathology.
• What impact does headache have on the patient’s quality of life, both during and between attacks?  This can be an open-ended question and improves consultation outcomes. 
• Family history. There is often a family history of migraine in migraineurs.
• What does the patient do during the headache? People with migraine will want to lie in a dark quiet room, people with cluster headache will pace the room and be agitated, tension-type headache will have little influence on activity.
• How often do they take painkillers? It is important to exclude medication overuse headache. This will occur if over a three-month period or longer the patient is taking analgesics on 15 days a month or triptans on more than 10 days.
• Are there precipitating or relieving factors? Relief by lying flat could indicate a low-pressure headache due to reduced CSF pressure. 
• A history of other medical conditions is important. There are many comorbidities associated with migraine, in particular anxiety, depression, sleep disorder, and other painful syndromes such as irritable bowel syndrome and fibromyalgia.

What are the most common diagnoses?
Migraine is by far the most likely diagnosis in primary care and many presentations of problematic tension-type headache will probably be migrainous in nature.  

Table 1 shows estimated rates of diagnoses as a percentage of all headaches presenting in primary care, drawn from literature. Any presentation of new headache over the age of 50 should raise suspicion of temporal arteritis.

Histories that require immediate attention

• Thunderclap headache – very severe headache that rises to its maximum in under a minute. This has several causes, with subarachnoid haemorrhage the most likely.
• Headache with visual disturbance or tinnitus, particularly in young obese females. Idiopathic intracranial hypertension must be excluded with fundoscopy. Normal fundoscopy excludes this diagnosis but an ophthalmic retinal assessment is always useful. Papilloedema always needs immediate assessment.
• New headache in patients aged over 50 years. Measure inflammatory markers, or if these are not available and clinical suspicion is raised of temporal arteritis (tender or non-pulsatile temporal artery, systemically unwell) start on steroids.
• Other considerations include meningitis and carbon monoxide poisoning.

Histories that may require urgent attention

• Cluster headache. Although the pathology is not life threatening, cluster headache is arguably the most painful condition known and has been termed ‘suicide headache’ because of sufferers taking their lives when experiencing or anticipating an episode. It is important not to delay a diagnosis. The pain is shorter than migraine, always periorbital and unilateral, associated with autonomic features on the side of the pain (ask the patient to take a video) and the patient is restless and agitated.
• Headaches that are precipitated (not exacerbated) by exertion, either through exercise or Valsalva-type manoeuvres. This has a 10% chance of an underlying pathology, either a space-occupying lesion or a Chiari malformation.
• Headaches that indicate a possible underlying tumour. In particular, cancer of breast, prostate or lung should raise suspicion of secondaries. Other worrying features are headache with other neurological signs or symptoms, headaches in older people, seizures and memory or personality changes.
• Headaches that wake the patient from sleep may reflect a raised intracranial pressure, but migraine and cluster can waken patients too. Headaches with a significant shift in pattern can be a cause for concern, but expertise is needed to recognise abnormal patterns, particularly in migraine.

Histories that require routine management

• Around 95% of headaches will be primary. Migraine will be the most common and 30% will be with aura. Any episodic problematic headache with increased sensation, particularly sensitivity to light, sound or movement is likely to be migraine. Around 5% will be chronic migraine, defined as headache on 15 days or more of the month, of which eight days are migraine. Chronic migraine is associated with a considerable burden of multimorbidity, anxiety and depression. 
• Tension-type headache is a dull, bilateral, featureless headache which often overlaps with migraine. In many cases, tension-type headache may be part of a migraine-type spectrum. 

NICE guideline CG150 provides evidence-based recommendations on assessment and diagnosis.⁶

Remote neurological examination
Although examination very rarely adds to management, there are signs that can be assessed using a video consultation. Observation of neck movement can be helpful to spot a cervicogenic headache. The patient can elicit temporal artery tenderness if present. A video explaining how to identify neurological signs remotely is available on the American Headache Society website.⁷

Remote treatment 
For the acute treatment of migraine, a prokinetic is useful because of the gastric stasis. Simple analgesia, such as an NSAID and a triptan can be prescribed for the pain. Be mindful that failure to respond to a triptan is not a class effect. If prevention is needed, a ß-blocker, amitriptyline or topiramate are the drugs of first choice. 

Amitriptyline is useful in tension-type headache. 

The potential for medication overuse headache should always be discussed. In other cases, management will depend on the diagnosis.⁶

Dr David Kernick is a GPSI in headache based at the Exeter Headache Clinic

References

1.  Bekkelund S and Müller K. Video consultations in medication overuse headache. A randomized controlled trial. Brain Behav 2019;9:e01344 
2.  Bekkelund S and Müller K. One-year remission rate of chronic headache comparing video and face-to-face consultations by a neurologist: randomized controlled trial. J Med Internet Res 2021;23:e30151
3.  Dias L et al. Headache teleconsultation in the era of Covid-19: Patients’ evaluation and future directions. Eur J Neurol 2021;28:3798-804
4.  Tepper S et al. Prevalence and diagnosis of migraine in patients consulting with their physician with a complaint of headache: data from the Landmark Study. Headache 2004;44:856-64 
5.  Kernick D et al. What happens to new-onset headache presented to primary care? A case-cohort study using electronic primary care records. Cephalalgia 2008;28:1188-95
6.  NICE CG 150. Headaches in over-12s: diagnosis and management. 2021. Link
7.  Roblee J. Facebook Live: Conducting a telemedicine neurologic examination. American Headache Society 2020. Link

Further resources
A range of management plans and patient information sheets can be found at exeterheadacheclinic.org.uk