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Primary care

10-minute consultation
Sharon K Bal, Gary R Hollingworth

This is part of A 32 year old woman comes to you complaining of

a series of recurrent frontal headaches. They started about a
Useful reading
occasional month earlier and have been steadily increasing in fre- Steiner TJ, Fontebasso M, Del Brutto OH. Clinical
articles on quency and intensity over the past few days. She men- review: headache. BMJ 2002;325:881-6
common tions stress at work and poor sleep.
problems in British Association for the Study of Headache
primary care (BASH). Guidelines for all doctors in the diagnosis
What issues you should cover and management of migraine and tension-type
Department of
Assessment—Is it a primary headache (tension, migraine, headache. www.bash.org.uk/bash/guidelines.htm
Family Medicine, or cluster) or secondary to an underlying cause?
Faculty of Medicine, History—This is the crucial step in diagnosis. Many spe-
University of
Ottawa, Ontario cialists advocate the use of a symptom diary, which
K1N 5C8, Canada patients can use at home to establish a temporal What you should do
Sharon K Bal pattern for their headache. A separate history is
senior resident Tension headache
required for each type of headache. Attention should
Gary R x Reassure her that episodic tension headache is self
Hollingworth be paid to the course and duration of each. Ascertain
associate professor the quality of the headaches (steady, pounding,
x Address contributory factors such as stress or mus-
Correspondence to: stabbing) and the intensity, perhaps by using a visual
culoskeletal abnormality (temporomandibular joint
S K Bal analogue pain scale. Ask about associated features such
sharon_k_bal@ disorders, dental malocclusion).
as ipsilateral rhinorrhoea (cluster headaches) or
yahoo.ca x Depression and drug overuse will affect treatment
preceding aura (migraines). Also ask about precipitat-
The series is edited success (analgesics and other drugs used to treat head-
by general ing and alleviating factors. Are there any predictable
ache can result in medication overuse headache).
practitioners Ann triggers? A family history may be relevant, as may caf-
McPherson and x Regular exercise and lifestyle change, including
feine intake and use of drugs or complementary medi-
Deborah Waller meditation, relaxation therapy, and cognitive training,
(ann.mcpherson@ cines. Explore psychosocial factors such as new
may help her if stress is a major component.
dphpc.ox.ac.uk) stressors, support, and her own fears and expectations.
x Drug treatment is less helpful but might include
The BMJ welcomes Examination—Begin with a general inspection: does she
contributions from
over the counter drugs or, infrequently, non-steroidal
look unwell? Standard checks, including blood pressure
general anti-inflammatory drugs. Avoid powerful analgesics
practitioners to the measurement, are important. Focused neurological
such as opioids.
series examination, including fundoscopy, will be needed if
diagnosis is uncertain or if you suspect an intracranial
BMJ 2005;330:346
pathology. Examine her head and neck thoroughly for
x Precipitating factors include menstruation, stress,
signs of meningitis, scalp tenderness, limited range of
lack of sleep, strenuous exercise, and certain foods.
motion, or muscle tension, as indicated by the history.
Using symptom diaries to identify triggers may help in
modifying these risk factors.
x Use a treatment ladder for pharmacological
Serious causes of secondary headache management, going up a step after a particular drug
• Intracranial lesion has failed on three occasions. Begin with simple oral
• Meningitis analgesia: paracetamol 1000 mg or ibuprofen 400 mg,
• Subarachnoid haemorrhage preferably in soluble form, as the first step. See the
• Temporal arteritis BASH guidelines (see Useful Reading) for details.
• Primary angle closure glaucoma x Indications for prophylaxis include a high number
of attacks despite acute treatment or suboptimal relief
Red flags signs (indicators of possible serious
with acute management. This is generally judged by
underlying pathology)
the patient. Effective prophylactic drugs should be
• Increased intracranial pressure (indicates
intracranial lesion or idiopathic (benign) intracranial continued for 4-6 months then withdrawn to establish
hypertension, a non-serious condition that can present continuing need.
with similar signs and symptoms to intracranial lesion)
• Night-time awakening (intracranial lesion) Cluster headache
• Neurological signs (intracranial lesion, meningitis) x Timely diagnosis is essential for this very painful
• Constitutional symptoms such as fever, weight loss condition. Luckily the symptoms are characteristic.
(meningitis, intracranial lesion) x Acute treatment includes oxygen (100% at 7 l/min
• Intensity—“worst headache of my life” (subarachnoid for 10-15 minutes at onset of attack), ergotamine or
haemorrhage) triptan nasal sprays, and intranasal lidocaine.
• Previous head injury x First line prophylaxis is verapamil, preferably short-
• New onset headache in people aged over 50 years acting (120-160 mg three or four times a day).
old (temporal arteritis, intracranial lesion) x Referral to a neurologist is standard: analgesics have
no role in management.

346 BMJ VOLUME 330 12 FEBRUARY 2005 bmj.com