Headache audit report
Headache is one of the most common neurological problems, with some estimates from the Association of British Neurologists suggesting that it accounts for 20% of all outpatient referrals in the UK. Headaches, however, can take many different forms and diagnosis is based upon the characteristics of the headache itself as well as any (often varied) symptoms.1
As such, headaches can have a substantial effect on the quality of life, work status, family life and social activities of a patient. Treatment often has two strands – those to relieve the acute symptoms and those of a preventive nature. In 2012, The National Institute for Health and Care Excellence developed a formal set of guidelines to clinicians in the UK regarding the treatment of headaches.
As such, headaches can have a substantial effect on the quality of life, work status, family life and social activities of a patient. Treatment often has two strands – those to relieve the acute symptoms and those of a preventive nature. In 2012, The National Institute for Health and Care Excellence developed a formal set of guidelines to clinicians in the UK regarding the treatment of headaches.
Much of the treatment currently available for all forms of headache is based upon the International Headache Society classification, of which a third edition is currently in development. This system emphasises the importance of using specific features and symptoms to reach a good diagnosis. Whilst some headaches are of a secondary nature, following head injury and trauma, infection or vascular disorders, the vast majority of those patients seen by Dr Cockerell and in the general population are those with primary headache disorders. The possible causes of such headache disorders are numerous, ranging from nerve ending stimulation to the role of serotonin and the release of vasoactive substances such as nitric oxide.2
Primary headache disorders can be broadly classified3 as migraine, tension-type headache and cluster headache/trigeminal autonomic cephalgias, although other subcategories and rarer forms of primary disorders do exist. In addition, a more broad diagnostic term of “chronic daily headache syndrome” may be applied to the above categories depending upon the frequency of the headache. Neuroimaging and neurophysiology are important for diagnosis and patients will often be asked to undergo CT and MRI scans or EEG tests.
Headache is a complex physiological phenomenon and may involve several biological factors and environmental influences that intertwine. Genetic influences are one such feature and, often, patients with a headache disorder will have a strong familial history of headache. Certain trigger factors, such as food items, alcohol or stress, can often precipitate headaches of all forms and there is certainly evidence to support the link between headaches and endocrine events, particularly those of puberty, menopause and oral contraceptive use in females.4
Pharmacological interventions represent the primary method of headache treatment that Dr Cockerell employs. Overlapping symptoms and diagnostic subtleties often mean that the use of such medication involves a degree of trial and error to find a suitable and effective drug and associated dose tailored to the individual patient. Patients are often advised to keep a headache diary to monitor and score frequency and severity of painful episodes as these are a useful tool for the clinician to assess progress and adjust drug and dose accordingly. Physiotherapy, osteopathy, acupuncture and other forms of alternative medicine may also be advised to hasten or aid the relief of symptoms. In certain instances, other clinical procedures or inpatient treatment may be required.
Primary headache disorders can be broadly classified3 as migraine, tension-type headache and cluster headache/trigeminal autonomic cephalgias, although other subcategories and rarer forms of primary disorders do exist. In addition, a more broad diagnostic term of “chronic daily headache syndrome” may be applied to the above categories depending upon the frequency of the headache. Neuroimaging and neurophysiology are important for diagnosis and patients will often be asked to undergo CT and MRI scans or EEG tests.
Headache is a complex physiological phenomenon and may involve several biological factors and environmental influences that intertwine. Genetic influences are one such feature and, often, patients with a headache disorder will have a strong familial history of headache. Certain trigger factors, such as food items, alcohol or stress, can often precipitate headaches of all forms and there is certainly evidence to support the link between headaches and endocrine events, particularly those of puberty, menopause and oral contraceptive use in females.4
Pharmacological interventions represent the primary method of headache treatment that Dr Cockerell employs. Overlapping symptoms and diagnostic subtleties often mean that the use of such medication involves a degree of trial and error to find a suitable and effective drug and associated dose tailored to the individual patient. Patients are often advised to keep a headache diary to monitor and score frequency and severity of painful episodes as these are a useful tool for the clinician to assess progress and adjust drug and dose accordingly. Physiotherapy, osteopathy, acupuncture and other forms of alternative medicine may also be advised to hasten or aid the relief of symptoms. In certain instances, other clinical procedures or inpatient treatment may be required.
Migraine
Migraine comprises the largest diagnostic group (53%) of patients that present in Dr Cockerell’s clinic and is usually defined as an episodic headache with certain associated features.5 Often migraine may occur without specific aura but simply as a recurrent headache with some malaise and nausea. However, in other patients the headache (either stabbing or throbbing in nature) is accompanied by a host of classical aura, such as visual flashes and spectra, nausea and vomiting, tingling and numbing sensations and an intolerance to sound and light. Patients may become sensitive to sensory changes in their environment and this may play a role in bringing on an episode, possibly allowing an individual to anticipate a migraine and adapt accordingly. If migraine persists for numerous consecutive days, the term chronic migraine may be applied, which may require more intensive therapy.
Avoiding excess caffeine and alcohol and regulating diet and sleep are vital in the management of migraine. However, in many cases, pharmacological intervention will be a necessity involving a combination of acute relief and a course of preventive drugs over the long term. Riboflavin, a natural remedy, is often recommended to relieve symptoms of headache at a dose of 400mg daily and this provides a useful adjunct to synthetic compounds.
Most patients will initially self-medicate an episode of headaches with common painkillers, such as paracetamol, and many such acute-attack medications can actually aggravate, induce and increase migraine, known as medication-overuse headache. The vast majority of patients have such a history and therefore the avoidance of analgesic use is a requisite for all migraine treatment, often substantially reducing headache frequency alone.
More specific acute migraine treatments – triptan medications – are available and these help to abort impending or ongoing attacks. Most commonly, 2.5mg Frovatriptan, nasal Zolmitriptan (Zomig™) and sublingual Rizatriptan (Maxalt™) are advised as emergency treatments during a migraine attack although others may be recommended by Dr Cockerell. Following failed treatments with classic analgesics, there is a clear clinical stratification regarding treatment with triptan/acute medication and after the first “tier”, drugs of a greater strength or dose may be tried as determined by the clinician.
Migraine comprises the largest diagnostic group (53%) of patients that present in Dr Cockerell’s clinic and is usually defined as an episodic headache with certain associated features.5 Often migraine may occur without specific aura but simply as a recurrent headache with some malaise and nausea. However, in other patients the headache (either stabbing or throbbing in nature) is accompanied by a host of classical aura, such as visual flashes and spectra, nausea and vomiting, tingling and numbing sensations and an intolerance to sound and light. Patients may become sensitive to sensory changes in their environment and this may play a role in bringing on an episode, possibly allowing an individual to anticipate a migraine and adapt accordingly. If migraine persists for numerous consecutive days, the term chronic migraine may be applied, which may require more intensive therapy.
Avoiding excess caffeine and alcohol and regulating diet and sleep are vital in the management of migraine. However, in many cases, pharmacological intervention will be a necessity involving a combination of acute relief and a course of preventive drugs over the long term. Riboflavin, a natural remedy, is often recommended to relieve symptoms of headache at a dose of 400mg daily and this provides a useful adjunct to synthetic compounds.
Most patients will initially self-medicate an episode of headaches with common painkillers, such as paracetamol, and many such acute-attack medications can actually aggravate, induce and increase migraine, known as medication-overuse headache. The vast majority of patients have such a history and therefore the avoidance of analgesic use is a requisite for all migraine treatment, often substantially reducing headache frequency alone.
More specific acute migraine treatments – triptan medications – are available and these help to abort impending or ongoing attacks. Most commonly, 2.5mg Frovatriptan, nasal Zolmitriptan (Zomig™) and sublingual Rizatriptan (Maxalt™) are advised as emergency treatments during a migraine attack although others may be recommended by Dr Cockerell. Following failed treatments with classic analgesics, there is a clear clinical stratification regarding treatment with triptan/acute medication and after the first “tier”, drugs of a greater strength or dose may be tried as determined by the clinician.
Long-term preventive treatments present more of a challenge in that some drugs may not be well tolerated by individuals and it may be necessary to try alternative drugs. All drugs prescribed by Dr Cockerell are started on a low dose and gradually increased to a reasonable, sustainable and effective therapeutic level. It is essential to get input from the individual patient regarding any treatment regimen and the choices available will be clearly explained with their respective advantages and disadvantages. The majority of patients who begin preventive therapy have become unresponsive to acute medication and if the patient reports an increasing frequency of headaches this is a good indicator of requiring longer-term treatment. Continued regular (over)use of analgesics will hamper the success of preventive treatments and therefore avoidance of such drugs is crucial.
In general, the following six drugs represent the main avenues of preventive therapy used by Dr Cockerell. As stressed already, preventive headache drugs often produce marked side effects or exacerbation of symptoms and each individual drug may be successful for some patients but unsuccessful for others. It may therefore be necessary for the patient to change their medication after a given period of time as arranged with Dr Cockerell. There is great variation between patients and some medications will have no effect, some will resolve all symptoms completely and others may resolve symptoms temporarily until the medication is stopped.
In general, the following six drugs represent the main avenues of preventive therapy used by Dr Cockerell. As stressed already, preventive headache drugs often produce marked side effects or exacerbation of symptoms and each individual drug may be successful for some patients but unsuccessful for others. It may therefore be necessary for the patient to change their medication after a given period of time as arranged with Dr Cockerell. There is great variation between patients and some medications will have no effect, some will resolve all symptoms completely and others may resolve symptoms temporarily until the medication is stopped.
- Propranolol – a beta-blocker drug that is prescribed at doses between 40-200mg per day but can cause reduced energy and lethargy and extremes of temperature. It cannot be prescribed for those patients who suffer from asthma.
- Topiramate – an anticonvulsant that is prescribed at doses between 25-100mg/day. Common side effects are numbing and tingling sensations, memory disturbances and insomnia.
- Flunarizine – this calcium-channel blocker is currently unlicensed in the UK but is used across Europe and America. It is proven to reduce the severity of acute attacks and prevent recurrences of migraine. It is prescribed at doses of 5-10mg/day and can cause depression and drowsiness.
- Amitriptyline – a tricyclic antidepressant that has the greatest success rate of resolving symptoms amongst patients. Prescribed doses vary due to different sensitivities of individual patients but are normally in the range of 10-40mg/day. Drowsiness can occur. Dothiepin is another possible route of tricyclic therapy and can additionally resolve insomnia.
- Gabapentin – an anticonvulsant that is usually taken at night due to possible sedation.
- Dihydroergotamine – usually reserved for when other routes of medication have been unsuccessful and/or if severe migraines persist continuously over 3-5 days. It has proven success as a specific acute migraine treatment although can worsen symptoms and cause vascular problems, therefore requiring monitoring. Dihydroergotamine is given as a 3-day inpatient course of intravenous therapy. Once successful remission from pain is achieved, other preventive treatments can be re-established.
In addition, Dr Cockerell often employs greater occipital nerve blocks as a means of pharmacological intervention, whereby nerves at the rear of the head – on one or both sides – are targeted to relieve head pain in the long term. Persistence may be required to see clinical improvement and it is often necessary to repeat the outpatient procedure with varying doses of the drug. Such nerve blocks are additionally used to treat the rare form of cluster headaches seen in only 0.1% of the population.
Chronic daily headache syndrome
Chronic daily headache comprises the other main diagnostic group under which most patients fall and often includes the sub-category known as tension headache. Such headaches are usually featureless in contrast to migraine, although migraine may also present chronically in some instances. Tension headaches may present following any form of head trauma or injury, however mild. Approximately one-third of chronic daily headache patients have chronic migraine (usually with associated analgesic overuse); the majority have tension-type headaches.
The classification of both tension headache and chronic daily headache is constantly being reviewed and the terms are often interchangeable. Not all chronic daily headaches are necessarily tension-type but there is substantial overlap. Chronic daily headache is usually described as headaches that persist for 15 days or more each month. The role of nervous tension, genetics and pain modulation within the central nervous system are all under investigation with regards to the causes of tension headache.
Due to the fact that the diagnostic criteria for migraine and chronic daily headaches overlap, the treatment options are, in the main, similar as well. Physiotherapy may have a greater role to play and, in particular, spinal and neck physiotherapy may address the origin of symptoms. Flunarizine has a greater rate of success in patients with chronic daily headache syndrome than in those with migraine but, once again, a combination of amitriptyline, dihydroergotamine, flunarizine, topiramate, propranolol and riboflavin are often required to achieve a successful outcome. If cluster headaches are suspected, it may be advised to begin treatment with steroid medication, such as that of prednisolone, although this is uncommon.
Approximately 90% of patients reach a successful outcome after treatment for headache of whichever form. The vast majority have a complete resolution of symptoms whilst some will have a substantial improvement in symptoms but may require ongoing investigations and medication.
Chronic daily headache syndrome
Chronic daily headache comprises the other main diagnostic group under which most patients fall and often includes the sub-category known as tension headache. Such headaches are usually featureless in contrast to migraine, although migraine may also present chronically in some instances. Tension headaches may present following any form of head trauma or injury, however mild. Approximately one-third of chronic daily headache patients have chronic migraine (usually with associated analgesic overuse); the majority have tension-type headaches.
The classification of both tension headache and chronic daily headache is constantly being reviewed and the terms are often interchangeable. Not all chronic daily headaches are necessarily tension-type but there is substantial overlap. Chronic daily headache is usually described as headaches that persist for 15 days or more each month. The role of nervous tension, genetics and pain modulation within the central nervous system are all under investigation with regards to the causes of tension headache.
Due to the fact that the diagnostic criteria for migraine and chronic daily headaches overlap, the treatment options are, in the main, similar as well. Physiotherapy may have a greater role to play and, in particular, spinal and neck physiotherapy may address the origin of symptoms. Flunarizine has a greater rate of success in patients with chronic daily headache syndrome than in those with migraine but, once again, a combination of amitriptyline, dihydroergotamine, flunarizine, topiramate, propranolol and riboflavin are often required to achieve a successful outcome. If cluster headaches are suspected, it may be advised to begin treatment with steroid medication, such as that of prednisolone, although this is uncommon.
Approximately 90% of patients reach a successful outcome after treatment for headache of whichever form. The vast majority have a complete resolution of symptoms whilst some will have a substantial improvement in symptoms but may require ongoing investigations and medication.
References
1 Silberstein SD (2004). Migraine. Lancet 363 (9406):381-391
2 Kumar P, Clark M. Clinical Medicine. Elsevier Science, 6th Ed.
3 Headache Classification Committee (2004). International Classification of Headache Disorders, 2nd Ed. Cephalgia 24 (Suppl. 1): 1-160
4 Goadsby PJ, Lipton RB, Ferrari MD (2002). Migraine. Current understanding and treatment. New Eng J Med 346: 257-270
5 Goadsby PJ. (2003). Chapter 16 - Headache in Clinical Neurology, 3rd Ed. by TJ Fowler & JW Scadding. Edward Arnold Publishing.
Updated February 2016
1 Silberstein SD (2004). Migraine. Lancet 363 (9406):381-391
2 Kumar P, Clark M. Clinical Medicine. Elsevier Science, 6th Ed.
3 Headache Classification Committee (2004). International Classification of Headache Disorders, 2nd Ed. Cephalgia 24 (Suppl. 1): 1-160
4 Goadsby PJ, Lipton RB, Ferrari MD (2002). Migraine. Current understanding and treatment. New Eng J Med 346: 257-270
5 Goadsby PJ. (2003). Chapter 16 - Headache in Clinical Neurology, 3rd Ed. by TJ Fowler & JW Scadding. Edward Arnold Publishing.
Updated February 2016