OVERVIEW
- Headache has a considerable impact upon the lives of sufferers but the condition is poorly managed
- The initial aim of the headache consultation is to exclude serious pathology
- Migraine is the most common headache presentation in primary care in both adults and children
- Analgesic-overuse headache is common and should not be overlooked
- An underlying brain tumour is a common concern for patient and GP. Only investigate if there is a sound clinical indication: investigation can cause more anxiety than it relieves
Introduction
Headache is one of the common symptoms presented in primary care. Like many other symptoms in this book it can represent either serious disease, a cause of long-term distress or be intermittent and self-limiting.
Epidemiology in primary care
Over a 3-month period, 70% of the adult population will experience headache. In total 4% of GP consultations are for headache and 4% of headache consultations will result in a referral to secondary care. Including school-age children, 20% of the population have headache that has an impact on their quality of life.
Of all headaches, 5% are secondary i.e. there is a demonstrable pathology (including infections such as influenza as well as serious disease) and 95% are primary i.e. there is no observable underlying pathology. Primary headache is classified according to its clinical presentation. Here the basis of the headache is probably at a molecular level although certain headache presentations can be identified with activity in specific areas of the brain. Migraine (annual prevalence 15% in females and 8% in males) and tension-type headache (annual prevalence 70%) are the most common primary headaches and the ones that show most variation in response to changing circumstances, including psychosocial stress. A full classification of headaches can be found at the International Headache Society (HIS) website: www.ihs-headache.org/).
Table 8.1 shows estimates of the incidence of some important headache presentations in primary care.
Table 8.1 Estimates of the incidence of some important headache presentations in primary care.
| Diagnosis | Incidence1 (%) |
| Migraine | 73 |
| Other primary headache (predominantly tension type) | 23 |
| Subarachnoid haemorrhage | 0.05 |
| Meningitis | 0.02 |
| Temporal arteritis | 0.02 |
| Primary tumour | 0.09 |
| Other secondary headache | 3.8 |
1Up to 10% of primary headaches can be complicated by medication overuse headache.
GP assessment
The aim of management for the practitioner is to exclude a secondary headache, diagnose the appropriate primary headache, reduce any factors modifying the primary headache and treat accordingly.
Typical features of functional symptoms
Tension-type headache
The mechanisms underlying tension-type headache are poorly understood. The headache is usually dull and bilateral, it is often occipital but may be fronto-temporal. It is the commonest cause of a headache that is present all day every day. Patients with tension-type headache will keep going, in contrast to those with migraine who will want to lie down in a quiet, darkened room. Tension-type headache often coexists with migraine and some argue that in many cases tension-type headache is part of the migraine spectrum and based on similar neural mechanisms.
Medication-overuse headache
Of all primary headaches 10% will be complicated by medication-overuse headache, which often presents diagnostic difficulties if not excluded. Medication overuse headache does not have specific clinical features, but should be suspected when headaches worsen in patients taking triptans or opioid containing analgesics on 10 or more days per month or paracetamol or NSAIDs on 15 or more days per month.
Typical features of organic symptoms
There are three types of headache to consider: headaches representing serious disease, migraine and the defined primary headache syndromes.
Headaches representing serious disease
It is essential when assessing patients with headache to consider serious causes. The main ones—but not all—are listed in Table 8.2 along with useful predictive features.
Table 8.2 Predictive features of serious causes of headache.
| Headache | Useful predictive features |
| Emergency | |
| Meningitis | No feature is invariably present The following are common: fever (85%), neck stiffness (70%), alteration in mental status (67%), jolt accentuation of headache (97%) |
| Subarachnoid haemorrhage | Consider if this is the patient’s worst ever headache The most common presentation is a ‘thunderclap headache’ that reaches maximum intensity within 10 s and lasts for a few hours 12% of such patients have a subarachnoid haemorrhage rising to 25% if examination is abnormal Other features include occipital location, nausea, neck stiffness, impaired consciousness |
| Temporal arteritis | Always think of this in anyone over 50 The headache can mimic the features of other headaches Check inflammatory markers, although 5% are normal |
| Others | Malignant hypertension (diastolic >120 and papilloedema); carotid artery dissection (injury); venous sinus thrombosis (pregnancy/hypercoagulable) |
| Urgent | |
| Tumours | See main text |
| Carbon monoxide poisoning | Ask about headache in other family members and type of heating |
Brain tumours
A major concern for patients and doctors is that a headache presentation reflects an underlying tumour. Brain tumours are uncommon among patients with headache in primary care. Around three-quarters occur in patients aged over 50.
The probability of a brain tumour in three clinical situations is shown in Box 8.1. In each of these situations the risk of tumour is less than 1%.
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