Let me at the start to talk about headache in general, then I will talk about migraine as a form of a chronic headache.
Headache (cephalalgia): Pain anywhere in the region of the head or neck.
Types of headache
Two main types:
- Primary headache ( no known underlying problem)
- Secondary headache ( Identified underlying problem)
Secondary headache is more serious than primary headache.
- Tension headache
- Cluster headache
- Post-coital headache
- Stabbing type headache
- Cough related headache
- Daily persistent headache
- Hypnic headache
- Thunderclap headache
- Raised intracranial pressure ( space occupying lesions, idiopathic intracranial hypertension)
- Subarachnoid haemorrhage or subdural haematoma.
- Meningitis or encephalitis.
- Sinus or cortical vein thrombosis
- Dissection of vertebral or basilar artery.
- Posterior eversible encephalopathy syndrome (PRES).
- Trigeminal neuralgia.
- Herpetic neuralgia
- Cranial arteritis
- Whip lash
- Systemic diseases such as hypertension, hyperthyroidism, diabetes mellitus, glaucoma, nasal sinusitis, temporo-mandibular joint problems, dental problems, or visual disorders, or depression and anxiety.
- Analgesia related headache.
About 1 in every 20 people seen by any general practitioner suffers from a headache. This means every medical professional has to deal with headache directly or indirectly. We (doctors) need to learn something about headache in any medical speciality or subspecialty.
For those who deal with headache ( GPs or Hospital doctors) they need to be aware and alert. They need to be up to date in their knowledge about headache (diagnosis & management) in order for any one of us to be able to help and manage patients who suffer from headache.
Patients have an important role in their headache management. The majority of headaches are diagnosed on the first consultation, and around 95% of primary headaches are diagnosed on a good clinical history. Patients need to be precise, concise, and truthful about their symptoms (without exaggeration), and in their replies to doctors’ questions. Also patients need to listen to their doctors carefully, and not to demand investigations. Patients also need to tell about their habits (smoking & alcohol), as well as their social life when they are asked about. A lot of stress, and anxiety of any nature might be responsible for the patient’s headache. Offering such informations to the treating doctor can be very helpful.
Making a diagnosis
Following a good clinical history, any doctor who deals with headaches would have a good idea about his/her patient’s type of a headache (primary or secondary), and that is the first step forward. A focussed examination might sometimes explore a hidden cause (cranial arteritis, idiopathic intracranial hypertension, under lying tumour, or raised blood pressure).
Most of primary headaches – once they were considered primary – do not require further investigations. It is the doctor’s job to decide which type of primary headache he or she is dealing with. Though in general, management of the different types of primary headache is not much different. Some might require more specific treatment.
Once a diagnosis was made, moving forward is much easier.
I do not consider medical treatment as the most important factor. It is a complementary factor in most of the cases. I do listen carefully to my patients, and consider their life style as an important contribution to their headache management. Good explanation and clear demonstration on paper sometimes helps a lot. If a brain scan was done in advance, it doesn’t take a long time to show that scan to my patient as it helps quite a lot.
Good explanation about the available medical treatment with the merits of each one, and the possible adverse effects helps patients to decide whether to take medications or not. It helps them to make a choice as well. I do encourage my patients to make the decision, and to be part of it when they ask me to make that decision.
Most of the time, I don’t discharge my patients with a headache on the first consultation. I prefer to see them again at least once. That in my view helps my patients quite a lot, and it makes them feel more relaxed and confident.
Many professionals consider that as unnecessary, and they may consider it “waste of money”, but I don’t see it that way. A patient who was discharged quickly will in the future ask their doctors to refer them back again to see a specialist. They often never see the first one who saw them on the previous occasion. A different specialist takes longer time for assessment, and in many occasions a second consultation (done by a different specialist or the previous one) would lead to more investigations, sometimes including a brain scan. All of those cost extra money, which could be saved if a bit of more attention was paid to the patient on the first consultation.