Neurological symptoms in primary care Part 4: Headache

You might reasonably conclude that the headaches that you get periodically are the direct result of working in the NHS. However, the reality is that nearly everyone gets headaches: most are benign but some may be cause for concern

The lifetime prevalence of headache is 96% (99% of women, 93% of men)¹ and nearly 90% of all people have a headache in a given year.² Over any 2 week period, 25% of the population will have a headache severe enough to take an analgesic.³ Approximately 180 million working days are lost each year in the UK because of headache,⁴ and on any one day 90,000 people will miss work because of a headache.⁵ Most people with headache treat themselves, with only between one and two per cent of sufferers presenting themselves to primary care with their symptoms,³ but even so this results in 44 consultations per 1000 patients per year.⁶

Headaches are either primary, or secondary to an underlying cause. Community surveys suggest that tension-type headache (TTH) causes about 70% of primary headaches, and migraine another 15%.⁷ However, this is not the proportion in which patients present their headache to primary care: 90% of the headaches seen are primary: 85% of these are due to migraine and 10% due to TTH.⁸ In over 60% of cases, secondary headache is caused by systemic infection and pyrexia.⁷

Around 20% of patients who consult because of headache will be referred to hospital: of these 70% will have a benign cause for their headache and in 20% no cause will be found.³ Some people find their headaches very worrying – ‘what is going on inside my head?’ – but in general the chance of a serious cause for the headache is extremely small. As well as controlling the headache (where possible) the other big task for primary care is to exclude serious disease.

There is a long list of possible causes of headache. The British Association for the Study of Headache (BASH) suggests that primary headaches can be divided into four sections (with subheadings), secondary headaches into eight sections (with subheadings), and they also throw in a couple of neuralgias as well.⁹ However, for practical purposes we can concentrate on TTH and migraine as these are by far the most common reason why our patients present with headache.

TENSION-TYPE HEADACHE (TTH)

TTH is the commonest type of primary headache, and is five times more common than migraine.² Most tension headaches are not presented to primary care, but even so a GP with a list of 2,000 can expect four or five new cases to present each year.¹⁰ The headaches may be episodic (less than 15 days a month) or chronic, often having been present for months or years.

The TTH headache lasts between 30 minutes and 7 days, is not associated with nausea or vomiting, but is sometimes associated with photophobia or phonophobia (but not both), and has at least two of the following characteristics:

• Bilateral
• Pressing or tight in character
• Mild to moderate intensity
• Not aggravated by routine physical activity

Despite the vivid language with which the sufferer may describe their headaches, normal activities are usually unimpaired. Indeed exertion, or regular more gentle exercise, often improves the symptoms.

Some sufferers will have symptoms of depression or anxiety, the treatment of which will help the headaches. Some will have been subject to recent emotional stress: identification of such stress can make a diagnosis of tension more acceptable.

Despite TTH being so common, the cause of the head pain is surprisingly uncertain. Emotional, psychological and muscular causes have been suggested,¹¹ so that the headache is not due to ‘tension’ in every case. Accordingly the term ‘tension-type headache’ is now preferred over the old ‘tension headache’.¹²

It may prove difficult to convince a patient with tension-type headache that psychological illness can cause physical symptoms. Pain is usually assumed to be associated with tissue damage, and painkillers may be thought of as simply masking the symptom without addressing the underlying cause. It is hard to believe that the pain does not represent some physical disorder, and that the persistence of the pain does not mean that further damage is occurring.

It is easier to understand that muscle overuse can cause pain, which is why your arms ache after carrying heavy shopping. Neck muscle ache can radiate over the scalp and cause headache. Such an explanation of tension-type headache may not be strictly true, but it is certainly plausible and emphasises the essentially benign nature of the headache.

TTH has traditionally been regarded as a sort of dustbin in which to deposit headaches for which it has not been possible to find a more medically interesting cause. Such a diagnosis of exclusion may partially satisfy a neurologist, but is unlikely to convince the patient who is more interested in what he has got rather than what he hasn’t got. Dissatisfied patients are less likely to go along with medical advice and less likely to get better.¹³

Response to treatment is usually disappointing, one diagnostic pointer being that simple analgesia is often only partially effective despite full dosage, and stronger analgesics confer little additional benefit. Indeed, the use of analgesics may actually make the headache worse. An explanation of the pain is all that some sufferers are after. Some patients will not take kindly to suggestions that their pain is psychosomatic as this will be taken as an inference that the pain is ‘imaginary’. It is usually not possible to cure TTH. Treatment may, however, reduce the frequency and severity of episodes.

TTH and migraine can coexist, a situation that used to be called ‘Combination Headache’. Treatment should be directed towards the most important headache for the patient, but migraine is usually easier to treat.

MIGRAINE

Typically migraine attacks start during the teens or early 20s, and it is rare for a first attack of migraine to occur over the age of 50.14 On average, each migraine sufferer gets one attack per month.¹⁴ The attacks often abate during middle age, but there is always a chance that the symptoms will return. The peak age for attacks is 20 to 40.¹⁵ Each day in the UK, 187,000 people have a migraine.¹⁶ It was estimated in 2008 that the overall cost of migraine was £2.25bn a year, including £150m in healthcare costs.¹⁷ On average a migraine sufferer will be impaired on 20 work-days a year: 8 days work absence and 12 days of reduced productivity.¹⁸

Migraine often causes more symptoms than just headache. For a migraineur, the pattern of each attack is more or less the same. Indeed, if there is a change in the pattern of the symptoms it is important to make a fresh assessment to find out if there is another cause for the headaches. The migraine sufferer is quite well between attacks, however severe they are. If a feeling of being unwell persists, this again casts doubt on the diagnosis.

A ‘premonitory phase’ occurs in 20-60% of sufferers, lasts for about a day before the headache, and causes subtle changes in mood or behaviour. There may be lethargy and yawning, or sometimes a feeling of extreme well-being. There may be insatiable hunger and cravings.

An ‘aura’ occurs in 25% of cases and consists of neurological symptoms which happen in the hour or so before the headache starts. Visual symptoms may include the highly characteristic ‘fortification spectra’ where objects appear to have battlement-shaped edges. Alternatively there may be focal motor or sensory symptoms, which may make the sufferer fear they are having a stroke. Such symptoms can be particularly alarming. Virtually all patients with aura have visual symptoms, a third of patients have sensory symptoms, two thirds have motor symptoms, and a fifth have trouble talking.¹⁹

The headache of migraine is typically severe and throbbing, and lasts from 4 to 72 hours. It is accompanied by either or both of nausea or vomiting and photophobia or phonophobia. The pain may occur all over the head but typically is localised to just one part, usually a hemisphere. It is throbbing in character, of moderate or severe intensity, and made worse by exercise.

There may also be a ‘resolution’ phase: as the headache fades, typical symptoms consist of tiredness, irritability, depression, and trouble concentrating.

Up to 50% of patients can help themselves by avoiding situations in which their migraine is likely to occur.²⁰ The link can be established by the use of a migraine diary where over a period of time the patient records any factors which might trigger an attack, and also the pattern of the attacks. The migraine process starts up to 2 days before the headache emerges, so the timing of the trigger has to be right.

Different triggers may be relevant in different migraine sufferers.²¹ They are cumulative, so that one or more triggers may increase the risk of an attack to a threshold beyond which an attack results.

MEDICATION OVERUSE HEADACHE

(MOH, previously ‘analgesic headache’)

If painkillers are taken regularly for headache, then overuse headache may result. It does not occur if the same analgesics are used for reasons other than headache.¹ The prevalence of MOH is about 1%, but 90% of those experience chronic daily headache. Almost any analgesic can cause MOH, particularly those containing codeine or caffeine, probably due to an alteration in neural pain pathways.²³

MOH is particularly likely when analgesia is taken in anticipation of getting a headache.¹ Around half of all patients with daily headache will have MOH in addition to the headache for which they started to take the analgesics. On average these are serious drug takers – using 6 different preparations on 35 occasions a week.²⁴

Treatment is difficult as after stopping analgesia the headaches may take up to 6 months to abate (but usually a lot less). The analgesia should be stopped suddenly, unless it is an opioid (i.e. codeine or stronger) in which case gradual reduction is required.^25,26

RED FLAGS

For each person who presents to primary care with headache, less than 2% will have serious underlying pathology.¹ On average a GP will see a new brain tumour once every 10 years. Brain tumour is rare. However, there are some other serious causes of headache and it is important not to miss serious pathology when it does arise.

When to suspect a serious cause for a headache^1,25

• For a possible intracranial bleed, there may have been a head injury and the headache is typically progressive and may be associated with impaired consciousness and/or focal neurological loss (e.g. weakness, balance problems).
• A sudden onset, severe and rapidly progressive headache (over seconds or minutes) may be a subarachnoid haemorrhage.
• Any headache associated with a sudden onset of neurological problems such as with speech, sensation, power, or consciousness – may be a stroke
• Fever and impaired consciousness, neck stiffness, or photophobia (possible meningitis).
• Tenderness over the temporal artery in a person older than 50 years of age (possible giant cell arteritis).

If there may be a space-occupying lesion (such as a brain tumour) then:

• The headache may be accompanied by vomiting, posture-related headache (worse when lying down), or headache waking them from sleep
• There may be focal neurological symptoms (e.g. localised numbness or weakness), or non-focal neurological symptoms such as blackout, change in personality or memory, new onset epilepsy.
• The headache becomes progressively severe.
• If your patient is already known to have had a cancer anywhere (possibly causing brain secondaries) or HIV, then the risk of a space-occupying lesion is greater.

CONCLUSION

Getting a headache is very common. Like the other neurological symptoms discussed in this series, some people find their headaches worrying and troublesome, and so may well turn up to your clinics and phone-lines in a state of alarm. Patients will have their own ideas, concerns and expectations about their headaches: identifying and addressing these is important for long-term management. It is usually not possible to ‘cure’ persisting headaches.

Most people with headache do not have a brain tumour, but some do: if there is a serious cause for the headache, then there will invariably be other symptoms as well.

REFERENCES

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