General Practice 10 Minutes Podcast on Headache Management with Dr Roger Henderson

10-minute clinic show notes Headache

A headache is one of the most common conditions seen in primary care and is characterised by pain in the head or neck, ranging from mild to severe. There are various types of headaches, including tension headaches (the most common, caused by stress and muscle tension), migraines (intense, throbbing pain often with nausea and sensitivity to light), cluster headaches (extremely painful and occur in clusters), sinus headaches (caused by sinus inflammation), and rebound headaches (due to overuse of headache medications).

Headaches can be primary (not linked to other medical conditions) or secondary (caused by underlying health issues). Common symptoms include head pain, sensitivity to light and sound, and nausea. Severe symptoms, such as confusion or loss of consciousness, require immediate medical attention and in this 10 minute clinic podcast we look at how to assess the patient presenting with a headache, including red flag symptoms that must not be missed, common differential diagnoses and principles of treatment.

Key take-home points

  • Headache affects almost everyone at some time. 
  • Headaches are more common in women than in men. 
  • They can be classified headaches into primary and secondary headache disorders.  Over 90% of headaches seen in primary care are primary headaches.
  • Tension-type headaches (TTH) are the most common type of headache. TTH characteristics are that they are bilateral, pressing or tightening in quality, mild-to-moderate in intensity and with no nausea. They are not made worse by physical activity.
  • Migraine headaches tend to be unilateral, throbbing and disproportionately disabling. Nausea is common and they can occur with or without aura. Visual symptoms are the most common manifestation of an aura and consist of flickering lights, spots or zig-zag lines, or blind spots.
  • Cluster headaches are characterised by attacks of severe unilateral pain in a trigeminal distribution. They are more common in smokers, men and adults. 
  • Secondary headaches include medication overuse headaches (‘rebound headaches’), head trauma headache and intracranial headaches
  • When assessing a patient with headache, look for more than one headache disorder being present. Check for any serious secondary cause, medication overuse and for migraine symptoms
  • Examination should include measurement of blood pressure, temporal artery palpation if the patient is over the age of 50, neurological examination and examination of the neck
  • If the cause cannot be diagnosed, use a headache diary and consider referral for assessment
  • Do not use opioids to treat headaches
  • Stress, sinus problems and eye strain are not usually the cause of headaches
  • Refer any case with red flag symptoms, with a new daily persistent headache, if trigeminal neuralgia is present or with cluster headaches
  • Medication overuse headaches are very common, and underdiagnosed. If suspected, stop analgesics and caffeine. Remind the patient their headaches are likely to worsen on stopping analgesics before slowly improving

References:

Overview | Headaches in over 12s: diagnosis and management | Guidance | NICE

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition (ichd-3.org)

Headache – assessment | Health topics A to Z | CKS | NICE

Red flags in patients presenting with headache: clinical indications for neuroimaging – PubMed (nih.gov)

NATIONAL Headache Management SYSTEM FOR Adults 2018

Patient resources:

Home – The Migraine Trust

OUCH(UK) – The Cluster Headache Charity | Support for Sufferers & their Families (ouchuk.org)

Headaches – NHS (www.nhs.uk)