Headache - Diagnosing, managing and preventing
Published in MedicineWise News
Date published: About this date
- Diagnosing headache
- Secondary headache red flags
- Managing headache
- Preventing headache
- Case Study 74: Recurring headache
- Headache resources
Headache is common. Global 1-year prevalence data show that about 1 in 2 people will suffer a headache: 4 in 10 of these will have a tension-type headache and 1 in 10 will have a migraine.A,1 We focus on headache diagnosis and the role of neuroimagingB, management and prevention (including non-drug strategies).2 This issue focuses on the diagnosis of three types of primary headache: episodic tension-type, migraine and cluster (Table 1).3 People often suffer from episodes of both tension-type and migraine headaches. There are no diagnostic tests for primary headache. Most are benign and investigations are not usually needed.2
Identifying a serious cause of a secondary headache is an essential part of the initial diagnosis. ’Red flag‘ symptoms and signs together with a comprehensive history and careful physical and neurological examination, indicate the need for investigation, such as neuroimaging (e.g. computed tomography [CT] scan or magnetic resonance imaging [MRI]).4
Once causes of secondary headache have been excluded, some guidelines suggest using a headache diary for a few weeks (e.g. 4–6 weeks).2,5,6 Patients can record details such as frequency, severity, suspected triggers and medicines use, and thus establish a baseline. Diary records are usually more accurate than a person’s recollection, and can inform discussion of the impact of headache on quality of life, ensure appropriate follow-up and monitor response to treatment.5,6
(Adapted from the International Classification of Headache Disorders, 2nd edition2)
Headache lasting 30 minutes to 7 daysAt least two of:
Headache lasting 4–72 hours
At least two of:
At least one of:
Differentiating between migraine without aura and episodic tension-type headache may be difficult:
Headache lasting 15–180 minutes
Secondary headache red flags
Consider secondary headache in anyone with new-onset headache or a headache different from their usual headache (Box 1); arrange for neuroimaging when any of these red flags are present.6,7
Box 1: Some ‘red flags’ when diagnosing headache5,8
A ‘new-onset’ headache in a person:
Headache associated with:
To image or not to image
Neuroimaging is usually not needed unless a red flag is present.2,7 Neuroimaging has risks and costs. These include risks of the procedure (e.g. exposure to ionising radiation or contrast media), risks related to interpreting the results (e.g. incidental findings see below, false positives/negatives), and both financial and logistic costs (e.g. out-of-pocket expenses to the individual, cost to the health system, waiting time, transport to and from the imaging facility).
Exposure to ionising radiation from a single head CT scan is estimated to increase the average lifetime attributable risk of death from cancer by 0.005% for a 45-year-old person.9 Although the individual risk is small, increasing CT use contributes to increased mortality at a population level.9 Radiation dose varies depending on the source: there is no ‘safe’ dose and all doses contribute to lifetime risk (Table 2).10 A 2005 report found that Australian GPs ordered a CT of the brain or head in around 1 in 10 headache problems.11
Bear in mind the medical, practical and ethical issues associated with incidental findings — neurological abnormalities incidental to the reason for neuroimaging. Incidental findings may cause patient anxiety and clinician uncertainty (which may result in further inappropriate investigations and/or treatment with associated risks). A recent Canadian audit of CT scans detected incidental findings in about 20% of cases (compared with about 2% of findings that were potentially related to headache).12 A meta-analysis showed one incidental finding for every 37 people who did not have neurological symptoms and who had a brain MRI (for either research purposes or occupational, clinical or commercial screening).13
Table 2: Some radiation sources and doses 10
|Source of radiation exposure||Radiation dose millisieverts (mSv)||Range (mSv)|
|Chest X-ray 2 views||0.08||0.05–0.2|
Managing headacheOf the many different types of primary headache, in this NPS News we focus on managing and preventing episodic tension-type, acute migraine and cluster headache. Other types of headache are not discussed: see NPS News 38 for more information on medication-overuse headache.14
Episodic tension-type headache
Episodic tension-type headacheD is the most common type of headache.5 It is self-limiting and non-disabling, so manage by providing information, reassurance and symptomatic relief as needed.2,15 Identifying and eliminating trigger factors (e.g. lack of sleep) can reduce headaches.2,5 If needed, treat with physical therapy (e.g. massage, stretching or postural correction5) or analgesics (e.g. aspirin, an NSAID or paracetamolE).2,5,15 Although the evidence is limited, other non-drug strategies such as regular exercise, physiotherapy, relaxation training, cognitive–behavioural therapy (CBT) and stress management training may be helpful.2,5,15,16
Acute migraineCompared with episodic tension-type headache, migraine is less common. But it can be severely disabling.1,7 As with other types of headache, people usually want to continue with their activities.2 However, some guidelines suggest combining drug treatment for migraine with rest or sleep in a dark and quiet room.2,5,17
Start with analgesics (aspirin, an NSAID or paracetamolE) and ensure these are taken in sufficient doses early in the migraine when absorption is less impaired by reduced gastrointestinal motility.5,6,18,17 Soluble or rectal formulations can be useful.5
Add an antiemeticF for nausea and/or vomiting and for people who do not respond to an analgesic alone.5,6,18 Antiemetics increase gastrointestinal motility and may improve absorption of analgesics.17 Small trials have shown that aspirin 900 mg or paracetamol 1000 mg with metoclopramide 10 mg provide migraine relief at 2 hours similar to that of sumatriptan 100 mg.19,20
If analgesics are consistently ineffective (e.g. for 3 migraines) or if migraine is severe, use a triptan or an ergot alkaloid.17 Individual response varies18: one guideline suggests trying one triptan for 3 migraines — including different doses and formulationsG — before trying another.2,21 While the use of an ergot alkaloid is limited by adverse effects (e.g. peripheral vasoconstriction) and is available in Australia in an injectable form only, it may be useful for some people.17,21 For more information about treating acute migraine, refer to guidelines or other publications.2,5,7,14,17
Cluster headache is rare and seen mainly in males.5 Cluster headache pain is severe, causing significant disability during the cluster period, and expensive to treat.2 A recent German study of people with cluster headache showed significant lost work capacity and treatment expenses.22 Acute treatment needs to relieve symptoms quickly because cluster headache has a rapid onset and a short time to peak intensity.23 Guidelines list first choice options as subcutaneous sumatriptan 6 mgH or oxygen 100% at 10–15 L/minI for 10–20 minutes (caution: there is a risk of oxygen toxicity).2,5,6,24 Combine acute with preventive treatment until the latter becomes effective and/or if further headaches occur.2 Preventing further headaches is the focus of therapy.2,5
Consider non-drug strategies first for preventing migraine. Most migraine sufferers are aware of avoiding factors that may trigger a headache (e.g. stress).17 Physical (e.g. exercise, yoga) and psychological (e.g. relaxation and/or stress management training, CBT) strategies can be helpful.2,5 These may have added benefit when combined with preventive drug therapy.5,16Consider preventive drug therapy when the patient has 2 or 3 severe migraines per month.5,17 One guideline defines successful preventive therapy as halving migraine frequency within 3 months.18 However, this is often unachievable, and people still need acute drug therapy.2 Preventive drugs are relatively non-specific and choice of drug means balancing individual response with tolerability. Minimise adverse effects by starting at a low dose and increase gradually to the lowest effective dose.17 It may be another 1–3 months before the full effect is seen.17 Withdraw after 4–6 months to assess continuing need (gradually, over 2–3 weeks to avoid rebound headache).2,17
For more information about preventive drug therapy for migraine, refer to guidelines or other publications.2,5,7,14,17
The aim of preventive therapy for cluster headache is to suppress headaches and maintain remission over the cluster period (usually 6–12 weeks2).24 Start preventive therapy as soon as possible after a new cluster period starts.2 Guidelines suggest verapamil as first choice: start with 240 mg a day, titrate according to efficacy and tolerability.J,2,6,24-26 Continue until all headaches have stopped for at least 7–14 days.2,5 Then withdraw by progressive dose reduction.2 In the first 2 weeks of verapamil therapy, guidelines suggest short course high-dose corticosteroids (e.g. prednis[ol]one) to suppress headaches until verapamil takes effect (sometimes called “bridging therapy”).2,5,6,24-26
A. Cluster headache was not reported because there are few population-based studies using International Headache Society criteria.[Back]
B. A collective term incorporating computed tomography (CT) and magnetic resonance imaging (MRI) of the head or brain.[Back]
C. Average yearly dose Australians are unavoidably exposed to.[Back]
D. Occurring on fewer than 2 days per week.[Back]
E. Overuse of all drugs (including aspirin and paracetamol) used to treat headache can cause headache, such as medication-overuse headache.[Back]
F. For example: domperidone, metoclopramide (also available as an injection) or prochlorperazine (also available in suppositories).[Back]
G. For example: sumatriptan is available on the PBS as a fast disintegrating tablet, injection and tablet.[Back]
H. Indicated but not PBS-listed for treating acute cluster headache (so it may be expensive).[Back]
I. Requires heavy cumbersome tanks and equipment from medical gas suppliers (most home oxygen equipment is for people with respiratory disease and only allow delivery of oxygen at concentrations that are not effective in cluster headache).[Back]
J. There is no agreement on an optimal or maximum verapamil dose; perform baseline electrocardiography before starting verapamil, repeat 10 days after each dose change.[Back]
Expert reviewersAlessandro S Zagami, Senior Staff Specialist in Neurology, Institute of Neurological Sciences, Prince of Wales Hospital Conjoint Associate Professor, Prince of Wales Clinical School, University of New South Wales
TJ Singh, Consultant Neurointerventionist and Neuroradiologist, Neurological Intervention and Imaging Service of Western Australia
Dr John Dowden, Editor, Australian Prescriber
Dr Graham Emblen, GP, Toowoomba
Dr Oliver Frank, GP, Hillcrest, South Australia
Dr Sarah Gani, GP and Medical Educator, Blacktown
Benafsha Khariwala, Managing Editor, Journal of Pharmacy Practice and Research
A/Prof Jennifer Martin, Head PA-Southside Clinical School
Deborah Norton, QUM Pharmacist, West Vic DGP
Any correspondence regarding content should be directed to NPS. Declarations of conflicts of interest have been sought from all reviewers.
- Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007;27:193–210.
- British Association for the Study of Headache. Guidelines for all health professionals in the diagnosis and management of migraine, tension-type headache, cluster headache and medication overuse headache. Hull: BASH, 2010. (accessed 13 December 2011).
- International Headache Society. IHS Classification ICHD-II. London: IHS, 2004. (accessed 13 December 2011).
- Schaefer PW, Miller JC, Singhal AB, et al. Headache: when is neurologic imagingin indicated? J Am Coll Radiol 2007;4:566–9.
- Neurology Writing Group. Therapeutic Guidelines: Neurology, Version 4 Updated November 2011 [eTG complete CD-ROM]. Melbourne: Therapeutic Guidelines Ltd, 2011.
- Scottish Intercollegiate Guidlines Network. Diagnosis and management of headache in adults. Edinburgh: NHS Quality Improvement Scotland, 2008. (accessed 19 December 2011).
- Zagami AS, Goddard SL. Recurrent headaches with visual disturbance. Med J Aust 2012;196:178-83.
- Mendelson R. Diagnostic imaging pathways - headache. Perth: Government o f Western Australia: Department of Health, 2011. (accessed 13 December 2011).
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- Wallace A, Cain T, Goergern S, et al. Radiation risk of medical imaging for adults and children. Inside Radiology. Sydney: The Royal Australian and New Zealand College of Radiologists, 2009. (accessed 23 February 2012).
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- You JJ, Gladstone J, Symons S, et al. Patterns of care and outcomes after computed tomography for headache. Am J Med 2011;124:58–63.
- Morris Z, Whiteley WN, Longstreth WT, et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009;339:b3016.
- National Prescribing Service Limited. Headache and migraine. NPS News 38. Sydney: NPS, 2005. (accessed 13 December 2011).
- Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurology 2010;17:1318–25.
- Sun-Edelstein C, Mauskop A. Alternative headache treatments: nutraceuticals, behavioral and physical treatments. Headache 2011;March:469–83.
- Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd, 2012.
- Evers S, Afra J, Frese A, et al. EFNS guideline on the drug treatment of migraine - a revised report of an EFNS task force. Eur J Neurology 2009;16:968–81.
- Kirthi V, Derry S, Moore RA, et al. Aspirin with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev 2010; 4: CD008041. (accessed 14 December 2011).
- Derry S, Moore RA, McQuay HJ. Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev 2010; 11: CD008040. (accessed 14 December 2011).
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- Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database Syst Rev 2010; 4: CD008042. (accessed 14 December 2011).
- May A, Leone M, Afra J, et al. EFNS guidelines for the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurology 2006;13:1066–77.
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