10-minute consultation Headache Sharon K Bal, Gary R Hollingworth
This is part of A 32 year old woman comes to you complaining of
a series of recurrent frontal headaches. They started about a Useful reading occasional month earlier and have been steadily increasing in fre- Steiner TJ, Fontebasso M, Del Brutto OH. Clinical articles on quency and intensity over the past few days. She men- review: headache. BMJ 2002;325:881-6 common tions stress at work and poor sleep. problems in British Association for the Study of Headache primary care (BASH). Guidelines for all doctors in the diagnosis What issues you should cover and management of migraine and tension-type Department of Assessment—Is it a primary headache (tension, migraine, headache. www.bash.org.uk/bash/guidelines.htm Family Medicine, or cluster) or secondary to an underlying cause? Faculty of Medicine, History—This is the crucial step in diagnosis. Many spe- University of Ottawa, Ontario cialists advocate the use of a symptom diary, which K1N 5C8, Canada patients can use at home to establish a temporal What you should do Sharon K Bal pattern for their headache. A separate history is senior resident Tension headache required for each type of headache. Attention should Gary R x Reassure her that episodic tension headache is self Hollingworth be paid to the course and duration of each. Ascertain limiting. associate professor the quality of the headaches (steady, pounding, x Address contributory factors such as stress or mus- Correspondence to: stabbing) and the intensity, perhaps by using a visual culoskeletal abnormality (temporomandibular joint S K Bal analogue pain scale. Ask about associated features such sharon_k_bal@ disorders, dental malocclusion). as ipsilateral rhinorrhoea (cluster headaches) or yahoo.ca x Depression and drug overuse will affect treatment preceding aura (migraines). Also ask about precipitat- The series is edited success (analgesics and other drugs used to treat head- by general ing and alleviating factors. Are there any predictable ache can result in medication overuse headache). practitioners Ann triggers? A family history may be relevant, as may caf- McPherson and x Regular exercise and lifestyle change, including feine intake and use of drugs or complementary medi- Deborah Waller meditation, relaxation therapy, and cognitive training, (ann.mcpherson@ cines. Explore psychosocial factors such as new may help her if stress is a major component. dphpc.ox.ac.uk) stressors, support, and her own fears and expectations. x Drug treatment is less helpful but might include The BMJ welcomes Examination—Begin with a general inspection: does she contributions from over the counter drugs or, infrequently, non-steroidal look unwell? Standard checks, including blood pressure general anti-inflammatory drugs. Avoid powerful analgesics practitioners to the measurement, are important. Focused neurological such as opioids. series examination, including fundoscopy, will be needed if diagnosis is uncertain or if you suspect an intracranial BMJ 2005;330:346 Migraine pathology. Examine her head and neck thoroughly for x Precipitating factors include menstruation, stress, signs of meningitis, scalp tenderness, limited range of lack of sleep, strenuous exercise, and certain foods. motion, or muscle tension, as indicated by the history. Using symptom diaries to identify triggers may help in modifying these risk factors. x Use a treatment ladder for pharmacological Serious causes of secondary headache management, going up a step after a particular drug • Intracranial lesion has failed on three occasions. Begin with simple oral • Meningitis analgesia: paracetamol 1000 mg or ibuprofen 400 mg, • Subarachnoid haemorrhage preferably in soluble form, as the first step. See the • Temporal arteritis BASH guidelines (see Useful Reading) for details. • Primary angle closure glaucoma x Indications for prophylaxis include a high number of attacks despite acute treatment or suboptimal relief Red flags signs (indicators of possible serious with acute management. This is generally judged by underlying pathology) the patient. Effective prophylactic drugs should be • Increased intracranial pressure (indicates intracranial lesion or idiopathic (benign) intracranial continued for 4-6 months then withdrawn to establish hypertension, a non-serious condition that can present continuing need. with similar signs and symptoms to intracranial lesion) • Night-time awakening (intracranial lesion) Cluster headache • Neurological signs (intracranial lesion, meningitis) x Timely diagnosis is essential for this very painful • Constitutional symptoms such as fever, weight loss condition. Luckily the symptoms are characteristic. (meningitis, intracranial lesion) x Acute treatment includes oxygen (100% at 7 l/min • Intensity—“worst headache of my life” (subarachnoid for 10-15 minutes at onset of attack), ergotamine or haemorrhage) triptan nasal sprays, and intranasal lidocaine. • Previous head injury x First line prophylaxis is verapamil, preferably short- • New onset headache in people aged over 50 years acting (120-160 mg three or four times a day). old (temporal arteritis, intracranial lesion) x Referral to a neurologist is standard: analgesics have no role in management.