The Scottish Intercollegiate Guidelines network have published full and quick reference guidance on headache management.
The NICE guidance on diagnosis and management of headache is available here.
Gloucestershire Neurology Guidance:
Who Needs A Scan? ( from JRCGP Dec 2008)
Red Flags (yield likely to be greater than 1%):
- Significant alteration in consciousness, memory, confusion, coordination
- New onset seizure
- New onset cluster headache (nb this is not a cluster of non-specific headaches)
- Headache with a history of malignancy elsewhere
- Headache with abnormal findings on neurological examination
Orange flags (yield likely to be greater than 0.1%):
- New headaches where no diagnostic pattern at 8 weeks
- Headaches worsened by exertion or Valsalva
- Headaches with vomiting
- Recent change in usual headache
- Patient over 50
- Headache waking patient from sleep
To scan or not to scan?
Frequently patients with headache feel they need to have a brain scan. They are often unaware of the reasons why we scan and the reasons why we might not. The common misconception is that the reason for not scanning is to save money.
The indications for a brain scan in headache are:
- As above, red and orange flags
- When the level of anxiety concerning a potential intracranial problem outweighs the potential harm in acquiescing to the patient's request.
Things that might help the discussion with the patient who “wants a scan”:
1. An atypical clinical history and a normal examination (see above) make it very unlikely that a scan will reveal an intracranial explanation.
2. CT delivers sizeable radiation dose (equivalent to fourteen chest X-rays). It is not as sensitive (to the majority of significant abnormalities) as MRI. It may be useful for the purpose of reassuring that an intracranial tumour is unlikely, but so may be a good history and examination.
3. MRI is very sensitive and very non-specific. There is a significant chance that it will show things that cannot be interpreted (eg dots and blobs) or show things that we do not know how best to treat or even if to treat (eg small aneurysms, benign tumours). Hence it has the potential for causing as well as for relieving anxiety.
4. In the case of individuals whose relatives have died of sub-arachnoid please see discussion below.
5. It may be more expensive to see the patient again or to refer them for an opinion than it is to request a scan. The decision not to scan should be made on clinical and common-sense grounds, rather than on financial grounds.
6. A scan is not the best way to manage a patient with a headache. An expert opinion may have more long term value.
Raised Intracranial Pressure Headache
The following are typical characteristics, on history and examination, of the headache associated with raised intracranial pressure.
- Rapid (days to months) progression
- Symptoms of focal neurology (eg dragging leg, clumsy arm)
- Waking the patient at night or early morning, worse on coughing or straining
- Papilloedema. A useful tip is that if you can see venous pulsation then it is exceptionally unlikely that intracranial pressure is raised. But bear in mind that 15% of the healthy population do not have venous pulsation either.
- Deteriorating level of consciousness
- Focal neurology (eg field defect, weak arm or leg, plantar up)
Most intracranial tumours do not present with headache, but with seizure or focal neurological symptoms and signs. If a sinister cause is suspected please refer the patient as URGENT, giving the symptoms and signs that raise that suspicion.
This causes a sudden (ask the patient how long from onset to peak), severe (what did it stop them doing?) headache that is often occipital. It may begin during sex or exercise (but is not the only headache that does so). It often causes immediate vomiting.
If a subarachnoid haemorrhage is suspected the patient should be admitted urgently for CT scanning (which is 97% sensitive) and lumbar puncture (which adds the other 3%). The combination of headache and a third nerve palsy is due to a posterior communicating artery aneurysm until proved otherwise.
Occasionally (but rarely, given the usual severity of symptoms) patients do not contact their doctor till some time after the event. SAH can be diagnosed by CT and LP up to one month after the event.
The role of screening for aneurysm is debated and a decision to screen needs to taken with the patient's full knowledge of the pro's and con's. The best screening method for aneurysm is cerebral angiography but this carries a significant risk (1% risk of stroke or death) and it is, in general, only offered to those with two affected first-degree relatives. MRI/MRA carries less risk but also has more false positives and false negatives. A recent study of incidental findings on MRI found aneurysm in 1.8% of the population (n=2000, mean age 63). If an aneurysm is identified then the risk of surgery or endovascular coiling needs to be less than the risk of leaving the aneurysm untreated. Checking and managing the vascular risk factors (hypertension, lipids, alcohol, smoking) is important with or without screening.
Always consider in the over 50’s. Diagnosed by symptoms (headache, temporal tenderness, jaw claudication), ESR/Viscosity and temporal artery biopsy. Biopsy can however be negative. If a temporal artery biopsy will be helpful, please phone on-call surgery.
The key clinical predictors to a diagnosis of migrainous headache are:
2. Duration 4-72 hours
It is recurrent, and is more common in women. There may or may not be an aura.
The management of migraine consists of diagnosis, managing the acute episode and considering prophylactic treatment. These subjects are well considered by Migraine Action and British Association for the Study of Headache (BASH).
Septrin sensitivity and Triptans
Sumatriptan and naratriptan both contain a full sulphonamide component and must be avoided in patients with sulphonamide hypersensitivity.
Almotriptan and Eletriptan both contain a sulphonyl component and are probably best avoided in patients with sulphonamide hypersensitivity.
Rizatriptan, frovatriptan and zolmitriptan contain no sulphur and carry no warning about sulphonamide hypersensitivity and are therefore the best option for patients with sulphonamide hypersensitivity.
Medication Overuse Headache
Headache can be a consequence of the medication a patient is taking for headache or pain from other sites. It is estimated to affect up to 1 in 50 adults, with a 5:1 female to male ratio, and can arise when medication is taken on more than two to three days per week. Opiate-based (eg tramadol, codeine, coproxamol, cocodamol, codydramol) medications are commonly responsible. It can also be caused by caffeine-based products and triptans. Management is by withdrawal.
Some patients develop headache after relatively minor trauma. Provided the trauma is minor (ie no loss of consciousness, no antegrade or retrograde amnesia) the patient is best managed by reassurance and encouragement. GRH has a clinic for patients with mild head injury and there is a hospital and community head injury team.
Referring the patient
When referring it would be very helpful for us to know the reason for your and their concern. It also helps to know the medications and strategies that the patient has tried. We would prefer it if patients weren't told that they were being referred for a scan. A scan may be helpful in diagnosis and management but can also be unnecessary or unhelpful.