Headache Management in Primary Care

 

Headache is a symptom that can arise from many disorders, which can be distinguished into three main groups:  primary headache disorders (such as migraines, tension-type headaches and cluster migraines); secondary headache disorders (such as head and neck trauma and cranial or cervical vascular disorders including giant cell arteritis and stroke); and cranial neuralgias (such as trigeminal neuralgia).  Of the more common primary headache disorders the lifetime risk of experiencing a tension headache is 70–80%, with the prevalence higher in men than women.  The prevalence of migraine is 18% for women and 8% for men.  For the less common primary headache disorders the prevalence of cluster headache is approximately 0.2% and is more common in men than in women.  It is estimated that about 2% of adults experience headaches due to medication overuse and is five times more common in women than in men.  Trigger factors for headaches can include stress, certain foods, missing meals, too much or too little sleep, bright lights, loud noise, and hormonal changes

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Types of headache

MIGRAINES WITHOUT AURA:  Lasting 4-72hrs, usually unilateral, pulsating, moderate to severe intensity, aggravated by normal physical activity, associated with nausea, vomiting, photophobia or phonophobia. (5 or more attacks to confirm diagnosis)

MIGRAINES WITH AURA:  Progressive, aura last 5-60 minutes prior to headaches.  Typical Aura includes homonymous visual disturbance, unilateral parasthesia/numbness, unilateral weakness, dysphasia, a combination of above. (2 or more attacks to confirm diagnosis)

TENSION TYPE:  Episodic or chronic, pressing or tightening and non pulsating, mild to moderate intensity, bilateral, not worse with activities, generally short lasting-no more than several hours

CLUSTER:  Ultra intense pain, unilateral, involving eye and frontal region, several times in 24 hours, can last 15-180 minutes. Associated symptoms: lacrimation, nasal congestion, rhinorrhoea, forehead/facial sweating, ptosis/miosis, eyelid oedema, very restless behaviour and inconsolable. Often occurs in bouts for 6-12 weeks, once a year or 2 years, often at same time of each year

HEADACHE WITH RAISED CSF PRESSURE:  Initially intermittent and then constant, pain is worse in a morning, and person may be woken by it. Headaches worse or provoked with change in posture, coughing, sneezing, straining or vomiting

TRIGEMINAL NEURALGIA:  Usually face, unilateral, characterized by lancinating pains limited to the distribution of one or more branches of trigeminal nerve. Pain is paroxysmal, lasting from 2 seconds to 2 minutes and described as intense, sharp, superficial, stabbing, burning or like an electrical shock. Between paroxysms the person is asymptomatic. The person can be free of pain at night

MEDICATION OVERUSE HEADACHES:  Associated with Opiates, aspirin, paracetamol, NSAIDS, triptans and ergotamine

  • Regular intake of NSAID >15 days a month or codeine-containing prescriptions >10 days a month
  • Often worse on waking and increase after physical exertion
  • Pre-emptive use of prescription in anticipation of rather than for headache
  • Diagnosis based on symptoms and drug use and confirmed only when symptoms improve after prescription withdrawn

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Exclude Red Flag Symptoms

NOTE:  Red flags do not indicate that a headache is necessarily sinister. However, in the correct clinical context, the presence of Red Flag features increases the level of concern. A comprehensive history and full neurological examination is essential

Exclude the following red flag features:

  • Sudden, severe worst-ever headache
  • Rapid build-up over 5 minutes
  • Impaired level of consciousness
  • Headache with pyrexia +/- vomiting
  • Progressive worsening over weeks/months
  • Headache with atypical or very focal aura
  • New aura on hormonal contraception
  • Cognitive changes including change in personality and behaviour
  • Recent head trauma within past 3 months
  • Headache provoked by physical activities – cough, sneeze, bend, straining, sports or sexual activity
  • Impaired immunity
  • New onset headache in patient with cancer

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Assessment and Diagnosis

Consider the possibility that more than one type of headache disorder is present, and undertake clinical investigation based on the order set out below

Assess for symptoms of:

  1. Serious secondary causes of headache that need immediate or urgent referral. If excluded, assess for:
  2. Medication-overuse and other secondary causes of headache. If excluded, assess for:
  3. Tension-type headache and migraine (the common primary causes of headache). If excluded, assess for:
  4. Less common causes of headache

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1. Serious secondary causes of headache

Suspect a serious cause if a headache:

  1. Follows trauma to the head and the headache is progressive, and especially if it is associated with impaired consciousness and/or a focal neurological deficit. If this occurs, suspect an epidural or subdural haematoma and arrange immediate admission
  2. Is sudden, with a rapid time to peak headache intensity (that is, from a few seconds to 5 minutes). If this occurs, suspect a subarachnoid haemorrhage and arrange immediate admission
  3. Develops simultaneously with a sudden onset of neurological impairment of speech, sensation, power, or consciousness, especially if the impairment lasts longer than 1 hour. If this occurs, suspect a transient ischaemic attack or stroke (including subarachnoid haemorrhage)
  4. Is associated with fever and impaired consciousness, neck stiffness, or photophobia. If this occurs, suspect an intracranial infection (such as meningitis or encephalitis) and arrange immediate admission
  5. Is associated with tenderness over the temporal artery in a person older than 50 years of age. If this occurs, suspect giant cell arteritis
  6. Is associated with features indicating a high risk of a space occupying lesion and/or idiopathic intracranial hypertension, such as anew headache accompanied by focal neurological symptoms, or non-focal neurological symptoms such as blackout, change in personality or memory, or accompanied by features suggestive of raised intracranial pressure, including papilloedema, vomiting, posture-related headache, or headache waking them from sleep
    1. NOTE: If the risk of a space-occupying lesion and/or raised intracranial pressure is considered to be high arrange urgent investigation either by urgent referral to a specialist (to be seen within 14 days), or direct referral for brain imaging from primary care, where this is available
  7. Is associated with features indicating a moderate risk of a space occupying lesion, such as a new headache when a diagnostic headache pattern has not emerged after 8 weeks, or a new headache in a person older than 50 years of age
    1. NOTE: If the risk of a space-occupying lesion is considered to be moderate monitor carefully and have a low threshold for investigation
  8. Is associated with severe unilateral eye pain, red eye, fixed and dilated pupil, hazy cornea, or diminished vision. If this occurs, suspect acute glaucoma and arrange immediate admission
  9. Is associated with nausea and impaired concentration in a person exposed to a potential carbon monoxide source, including smoke, engine exhausts, or gases from gas or solid fuel appliances retained in an enclosed space

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NOTEIf symptoms of a serious cause of headache are excluded, assess for medication-overuse and other secondary causes of headache

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2. Medication overuse and other secondary causes of headache

Exclude symptoms of serious secondary causes of headache, before considering other secondary causes

Suspect medication-overuse headache (MOH) in people with tension-type headache (TTH) or migraine, when they experience a chronic headache (headache on more than 15 days a month) that develops or worsens with frequent use of any pain relief medication.  MOH resolves following withdrawal of symptomatic treatment

Suspect other secondary causes when headache is associated with:

  1. Pain that is localized to structures in the head and neck (such as the eyes, ears, sinuses, temporomandibular joint, teeth, or neck) indicative of conditions such as acute otitis media and sinusitis
  2. Fever or general malaise and evidence of systemic infection
  3. Medications known to cause headache, such as nitrates and calcium channel blockers
  4. Caffeine withdrawal, in people consuming frequent caffeinated drinks such as tea, coffee, or colas
  5. Head or facial pain in the area of a herpetic eruption

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NOTE If a secondary cause for headache has been excluded, assess for tension-type headache and migraine (common primary causes of headache)

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3. Tension-type headache and migraine

Exclude symptoms of serious secondary causes and other secondary causes of headache before considering a diagnosis of tension-type headache or migraine

Suspect migraine in people who present with a pattern of recurrent episodes of severe disabling headache associated with nausea and sensitivity to light, who have a normal neurological examination

  • Diagnose migraine without aura when there are recurrent episodes of headache, lasting between 4 hours and 3 days, associated with either nausea or vomiting, or photophobia and phonophobia, or both and with at least two of the following characteristics:
    • Unilateral (more commonly bilateral in children)
    • Pulsating in character
    • Moderate-to-severe in intensity
    • Aggravated by routine physical activity
  • Diagnose migraine with aura when typical symptoms of migraine are preceded by the onset of an aura consisting of visual or sensory symptoms or dysphasia. Symptoms develop gradually and are fully reversed within 1 hour
    • Visual symptoms include flickering lights, spots, lines, or loss of vision
    • Sensory symptoms include pins and needles, or numbness
  • Migraine in children may last between 1 hour and 3 days and is usually bilateral and frontotemporal
  • If migraine is diagnosed see Migraine under Management below

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Suspect tension-type headache if the person presents with bilateral headache that is non-disabling and neurological examination is normal

  • Diagnose tension-type headache when there are recurrent episodes of headache, lasting between 30 minutes and 7 days, not associated with nausea or vomiting, but sometimes associated with photophobia or phonophobia, but not both, and with at least two of the following characteristics:
    • Bilateral
    • Pressing or tightening in character
    • Mild-to-moderate in intensity
    • Not aggravated by routine physical activity
  • If tension-type headache is diagnosed see Tension type under Management below

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NOTE If secondary causes, tension-type headache and migraine have been excluded assess for Less common causes of headache

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4. Less common causes of headache

Exclude symptoms of serious secondary causes and other secondary causes of headache, and tension-type headache and migraine, before considering less common causes of headache

Episodic unilateral facial pain, lasting a few seconds to 2 minutes

  • Diagnose trigeminal neuralgia when it is occurs in areas supplied by divisions of the trigeminal nerve, is sharp, stabbing, intense in character, and triggered by a trivial stimulus, such as light touch. If diagnosed see Trigeminal neuralgia under on Management below

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Episodic unilateral headache that is severe and orbital, supraorbital, or temporal:

  • Diagnose cluster headache when:
    • Severe pain lasts between 15 minutes and 3 hours, and is associated with intense restlessness and agitation, and may be triggered within 90 minutes of drinking alcohol
    • Episodes occur between one every other day and eight-times daily, often waking the person at night
    • At least five episodes of pain have occurred
    • The headaches are associated with at least one of the following ipsilateral autonomic features of forehead and facial sweating, conjunctival injection or lacrimation, eyelid oedema, miosis or ptosis, nasal congestion or rhinorrhoea
  • If cluster headache is diagnosed, see Cluster headache under Management below

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  • Diagnose paroxysmal hemicrania when:
    • Pain lasts between 2 minutes and 30 minutes
    • Episodes occur more than five times a day more than half of the time, although periods with lower frequency may occur
    • At least 20 episodes of pain have occurred
    • Pain responds completely to therapeutic doses of indometacin
    • The headaches are associated with at least one of the following ipsilateral autonomic features; forehead and facial sweating, conjunctival injection or lacrimation, eyelid oedema, miosis or ptosis, nasal congestion or rhinorrhoea
  • If paroxysmal hemicrania is diagnosed, continue treatment with indometacin and refer for specialist management

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Persistent unilateral headache:

  • Is diagnosed as hemicrania continua when it is a moderate-intensity headache with severe exacerbations and is:
    • Associated with at least one of the following ipsilateral autonomic feature; conjunctival injection or lacrimation, miosis or ptosis, nasal congestion or rhinorrhoea
    • Unremitting, and has lasted for more than 3 months
    • Completely responsive to therapeutic doses of indometacin
  • If hemicrania continua is diagnosed, continue treatment with indometacin and refer for specialist management

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If the cause of the headache can not be diagnosed, consider:

  • Asking the person to record a headache diary, and reviewing this in a few weeks
  • Referral for specialist assessment

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Management and Referral

Medication overuse headaches

NOTE The only treatment of established medication overuse headache (MOH) is complete withdrawal of all overused acute headache medications

  1. Advise the person to stop taking all overused acute headache medications
    1. Medication should be stopped for at least 1 month
    2. Withdrawal of ergots, triptans, and non-opioid analgesics should be abrupt
    3. Withdrawal of opioids and benzodiazepines usually needs to be gradual to minimize withdrawal symptoms
  2. Provide close follow-up and support according to the individual's needs
    1. Consider adjunctive treatment, such as antiemetics, if the person is not able to manage withdrawal because of withdrawal symptoms
  3. Consider prophylactic treatment for the underlying primary headache disorder
    1. Ideally wait for 1–2 months following withdrawal of overused medication before considering prophylaxis
    2. Occasionally, for a person who is unable to otherwise withdraw from the overused medication, prophylactic treatment may be considered in addition to withdrawal
    3. The choice of prophylactic treatment will depend on the underlying primary headache disorder
  4. Review in 4–8 weeks of the start of withdrawal of overused medication to:
    1. Review the diagnosis of MOH
    2. Assess the need for further management of an underlying primary headache disorder
      1. Overused medications may be re-introduced, with explicit restrictions on their use
      2. Consider prophylaxis for primary headache disorders

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Referral

NOTE:  Most people with medication overuse headache can be managed in primary care

Consider specialist referral for people with medication overuse headache who:

  • Have MOH caused by an opioid or opioid-containing drug as gradual withdrawal may be necessary
  • Have significant coexisting conditionsincluding:
    • Psychological problems (such as anxiety or depression), especially if the person is thought to be at increased risk of suicide
    • Physical problems, such as angina or diabetes especially if the person is elderly or frail
    • Pregnancy
    • Painful conditions requiring continued symptomatic treatment
  • Have had previous attempts at withdrawal of overused medication that have been unsuccessful
  • Are poorly motivated to stop symptomatic treatments

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Tension type headaches

Episodic tension type headaches

Episodic tension type headache is tension type headache that occurs on less than 15 days a month

  1. Reassurance and symptomatic treatment is usually sufficient.  Listen to and address the person's concerns about their symptoms
  2. Treat acute tension-type headache (TTH) with paracetamol, aspirin, or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen.  Aspirin should not be used in people aged less than 16 years old
  3. Do not treat acute TTH with opioids or triptans
  4. Consider preventative treatment for people with frequent episodic TTH (requiring analgesia on 2 days or more each week)

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Chronic tension type headaches

  1. Exclude a diagnosis of chronic migraine.  There is significant overlap between chronic TTH and chronic migraine; frequently migrainous features are present
  2. Investigate/exclude the possibility of medication overuse headache
  3. Identify and treat clinical depression
  4. Identify and manage trigger factors when possible
  5. Consider preventative treatment for people with chronic tension-type headache that does not respond to the above measures

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Preventing chronic/frequent tension headache

For people with frequent episodic or chronic tension type headache consider:

  1. Acupuncture — a course of up to 10 sessions of acupuncture over 5–8 weeks is recommended
  2. Pharmacologic prophylaxis with amitriptyline.  Titrate up to a dose of 75 mg at night, or the maximum tolerated dose, and review
  3. Refer to a neurologist or a GP with a special interest in headache, if there is a poor response to treatment, for expert assessment of the cause of the headache and its management

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Cluster headaches

  1. Discuss the need for neuroimaging for people with a first bout of cluster headache with a GP who has a special interest in headache or a neurologist
  2. For acute treatment of cluster headache, offer a subcutaneous or nasal triptan to be taken when required.  Subcutaneous sumatriptan 6 mg is the most rapid and effective treatment.
  3. For acute treatment, also arrange provision of home and ambulatory oxygen therapy.  Use 100% oxygen at a flow rate of at least 12 litres per minute via a non-rebreathing mask and a reservoir bag.  NOTE: 100% oxygen is contraindicated in people with chronic obstructive pulmonary disease
  4. Do NOT offer paracetamol, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), ergot, or oral triptans for the acute treatment of cluster headache
  5. Consider prophylactic treatment of cluster headache with verapamil
  6. Advise the person to avoid drinking alcohol or inhaling volatile fumes from substances such as solvents or oil based products, as these may trigger an attack during an active period of cluster headaches

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Referral

  1. Discuss the need for neuroimaging for people with a first bout of cluster headache with a GP who has a special interest in headache or a neurologist
  2. There is no need to refer people with recurrent cluster headaches unless they have developed with new symptoms or signs suggesting a serious underlying secondary cause
  3. Consider the need for further investigations and referral in people who have symptoms or signs suggestive of a space occupying lesion and/or raised intracranial pressure. The urgency of referral will depend on clinical judgement
  4. Seek specialist advice before starting prophylaxis with verapamil if unfamiliar with its use for cluster headache; if the cluster headache does not respond to prophylaxis with verapamil; of if treatment for cluster headache is needed during pregnancy

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Community Headache Service

The community headache service will provide treatment and advice to patients who suffer from headaches, negating the need for a referral into secondary care neurology outpatients.  The clinical lead will undertake a comprehensive assessment of patients and administer treatment whilst offering support and advice.  The clinical lead will also follow up patients as necessary, monitoring medications and making changes as appropriate.  Botox will be recommended as a treatment option for adults suffering from chronic migraines

Urgent referrals will be seen in the next clinic or referred to the Acute Trust.  Non-urgent referrals will be seen within 4 weeks of referral

The service is available for patients aged 16 years and over, and excludes those with red flag symptoms, those requiring emergency access, and acute medical presentations

Clinics are held at St Stephen’s Health Centre in Ashford and Bethesda Medical Centre in Cliftonville, Margate

Click here to access the referral form for all referrals, which are co-ordinated and processed by Bethesda’s GPwSI Single Point of Referral Centre

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Information to include on referral

Diagnostic Investigations

In order for the referral to be accepted the following must have been requested:

  • MRI/CT brain
  • FBC
  • ESR
  • U+E
  • TFT

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A comprehensive clinical history including:

  • Co-morbidities
  • Sleep disturbances
  • Mental health issues
  • Musculo-skeletal problems

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A full drug history of all preventative drugs and acute rescue therapies:

  • What has been tried?
  • Combinations?
  • Doses?
  • Period of treatment?
  • Reason for stopping?
  • Side-effects?
  • Any over the counter drugs?
  • Weekly/monthly usage of analgesia and Triptans – excessive?

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Your neurological examination findings:

  • Mental state
  • Speech
  • Cranial nerves
  • Sensation
  • Tone and power testing of limbs
  • Coordination and gait

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Other Information

  1. Please document exactly what clinical examination has been performed. Please do not write just “CNS = NAD” or “grossly normal”
  2. Include all results of completed investigations.  If imaging has taken place please state at which hospital and include a copy of the report
  3. If a scan is pending please state the type of scan that has been commissioned and where and when the procedure is due to take place
  4. It is essential that if the patient has seen a Neurologist in the past please include copies all letters and results

Ensure inappropriate drugs such as Codeine, Co-codamol, Tramadol and opiates are discontinued before referral – they have NO role to play in the management of most headaches

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Ask the patient to keep a simple headache diary to include:

  • Duration of each headache
  • Time of day at onset
  • Provocations
  • Document the frequency of headache
  • Response to treatment – indicate dose and combinations

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

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Radiology

For MRI/CT scans you can refer a patient to one of the following acute or community radiology providers (find details here)

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

Get in touch