‘Underestimated and under-treated’: Easing the burden of headache

Morgan Liotta

13/09/2019 11:07:42 AM

How can GPs best assess and diagnose headache and migraine, and establish an effective management plan for their patients?

Migraine aura
‘Some patients would describe a visual aura so intense that they cannot see clearly for multiple minutes,’ neurologist Dr Benjamin Tsang said of migraine.

Most people will experience headache in some form or another, ranging from a tension-type headache that can be eased with paracetamol, to chronic migraine that affects quality of life.
A headache is not only painful, but can also be disabling.
The World Health Organization (WHO) estimates that almost half of the world’s adult population has experienced headache at least once within the last year. The WHO’s 2013 Global Burden of Disease Study found headache disorders the third highest cause of years lost due to disability, with migraine the sixth highest.
‘Headache has been underestimated, under-recognised and under-treated throughout the world,’ the WHO reported.
Headache and Migraine Awareness Week aims to support the more than five million Australians affected by headache and migraine, delivering nationwide seminars and webinars from experts in the field.
The American Headache Society published in its journal Headache that one of the greatest challenges in this area of medicine is the identification of secondary headache disorders.
‘The signs and symptoms of secondary headache disorders can sometimes be subtle’, the article states, recommending that doctors ask patients specific questions to identify ‘red flags’ of secondary headache disorders, conduct a detailed neurological examination and perform appropriate testing to establish a diagnosis.
Dr Benjamin Tsang, a neurologist at the Sunshine Coast University Hospital, agrees that routine screening is important to determine the type of headache, and to then tailor appropriate treatment for primary or secondary headache.
‘GPs are in a key position to help assess and diagnose migraine, given patients will always present to a GP first,’ he told newsGP.
‘Whilst there is no biomarker [ie blood test or scan] for diagnosing migraine with confidence, a thorough history and examination will allow the GP to confidently diagnose migraine, then focus on treatment.’
A good place to start is the ID-Migraine screening questionnaire, which Dr Tsang describes as a useful tool for GPs.
The questionnaire asks patients if, during the last three months, they have had any of the following symptoms concerning headache pain:

  • Did you ever feel nauseous when you had headache pain?
  • Did the light trouble you (much more than when there is no headache)?
  • Did your headache ever limit your ability to work, study or do something you needed to, for at least one day?
‘If the answer is yes to at least two of the three questions, there is a very high sensitivity for diagnosing migraine, and sensitivity is even higher if all three are answered yes,’ Dr Tsang said.

Neurologist Dr Benjamin Tsang beleives routine screening is important to determine the type of headache, and to then tailor appropriate treatment for primary or secondary headache.

Typically, Dr Tsang says the examination is normal in migraine, but if abnormal, then it would prompt consideration for secondary headaches. He recommends the SNOOP4 questionnaire as a useful mnemonic to help rule out secondary headaches.
‘Often a patient is not aware they have migraine when they present to their GP and may think it could be a sinister secondary cause for headache,’ he said. 
‘Hence, GPs have the opportunity to diagnose migraine clinically, and offer the opportunity to not over-investigate the problem, which may cause its own problems; for example, incidental neuroimaging findings are common, and not without psychological sequelae when discovered.’ 
The RACGP’s Clinical guidance for MRI referral: Unexplained chronic headache identifies that abnormalities detected on neuroimaging may not be clinically significant, but may lead to further unnecessary investigations or interventions, and that serious causes of secondary headache are rare, including tumour and infection.
The guidelines also state the benefit of neuroimaging is in detecting significant and treatable lesions with impact on quality of life, and patients presenting with headache alone are unlikely to have such lesions.
Dr Tsang acknowledges the value of early screening and treatment in primary care, to help ease the potentially debilitating impacts of headache and migraine.
‘Patients can experience prolonged, severe attacks of headache which render their livelihood and work difficult,’ he said. 
‘Sometimes it can be the migraine aura, the prodrome or postdrome symptoms that are more disabling that the headache itself. For example, some patients would describe a visual aura so intense that they cannot see clearly for multiple minutes.’
If left untreated, Dr Tsang said there are significant long-term effects on a person’s life.
‘Chronic migraine can severely affect the quality of life of our patients,’ he said.
‘Episodic migraine can transform into chronic migraine, which affects around 2–3% of the population at any one time – this is defined as having more than 15 headache days per month, of which at least eight days are migrainous, for at least three months duration.’

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Dr Meghna Gupta   29/06/2023 1:13:33 PM