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Key questions on primary headache disorder

Key questions on primary headache disorder

GP and headache specialist Dr Richard Wood answers key questions on primary headache disorder, including how to reach a definitive diagnosis of migraine, best management approaches for migraine and tension-type headache and how to recognise and treat other types such as cluster headache

Key points

  • Primary headache disorder refers to headaches without underlying pathology, trauma or systemic disease. Around 99% of presentations are migraine or tension-type headache (TTH).
  • ‘Green flags’ for primary headache include: headache is episodic; ongoing headaches since childhood; stereotypical course; temporal relation with menstrual cycles; family history; normal neurological exam and blood pressure.
  • Secondary headache usually presents with other features, notably sudden onset, focal neurological deficit (eg, personality changes), systemic features such as night sweats or new headache in patients over 50.
  • Management of migraine involves identifying and managing triggers, and pharmacological acute and preventer therapies that are tailored to the patient’s lifestyle and preference. TTH tends to be seen on a spectrum with migraine, with patients often having features of both, and can be managed with a migraine treatment approach.
  • Analgesic overuse headache is a common cause of chronic daily headache and often related to opioid use.

1. What is primary headache disorder and what are the main groups within it? How common are they?

In its purest form, a primary headache disorder refers to headache disorders that include migraine, tension-type headache (TTH), and trigeminal autonomic cephalalgia (‘TACS’). There are a number of others,1 and as a general rule these are headaches which don’t have an underlying causative pathology, trauma or systemic disease. Their diagnosis is by phenotype – the description of the headache. A careful history is key.

The term ‘primary headache’ is of partial usefulness. Primary headache disorders will have their own underlying pathological mechanisms. And one of the most common ‘primary’ headache disorders – migraine – often reflects a disorder of homeostasis: some imbalance (or change) in the person’s life, environment, or body. Migraine and TTH, for example, can be worse around systemic upset, trauma, or other disease process (such as high blood pressure).

Headache is mentioned in one in 10 GP consultations, and is the reason for attendance in one in 25 consultations (two per day for the average GP).2,3 The large majority of these presentations, around  95%, are migraine, though we only make that diagnosis 17% of the time. Another 3-4% are troublesome TTH (which, in effect, we treat similarly to migraine, so the distinction is rather moot – TTH and migraine probably lie on a spectrum). This means approximately 99% of headaches presenting to you are migraine or TTH.

Headache specialists work to the maxim that in a primary care setting, a patient who presents with a stable pattern of episodic headache with a normal neurological examination and blood pressure should be assumed to have migraine until evidence presents to the contrary. That way, we will manage more headache more effectively.

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Dr Richard Wood is a GPwSI in headache. He runs a headache clinic for Oxford University Hospitals NHS Foundation Trust and is Education Fellow at the National Migraine Centre.


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