Headache for healthcare providers

Headache treatment guidelines(external link) Northland DHB Neurology, HealthPoint, NZ
Headaches in childhood guideline(external link) Starship Children's Health, Auckland DHB, NZ

Key information about headache provided by Dr Pyari Bose, neurologist, Auckland

Primary headache disorders

Primary headache disorders like migraine and cluster headache form the major bulk of referrals to a neurologist. Every year it is estimated that 3 billion people worldwide are affected. Though these disorders are not life threatening, they can lead to major disability with heavy socioeconomic consequences.

Patients sometimes find it hard to access resources for diagnosis, management and support and hence raising medical awareness is paramount. New advances in the understanding of the disorders and novel therapeutic developments takes us to an exciting era in management. New acute therapies for migraine attacks like gepants, calcitonin gene-related peptide (CGRP) receptor antagonists, and serotonin 5-HT1F receptor agonists, offer novel approaches to the treatment.

See the following for more information about specific primary headache disorders:

Tension headache – information for clinicians
Migraine headache – information for clinicians
Cluster headache – information for clinicians

Secondary headache disorders

These are headaches caused by an underlying condition. Clinicians who evaluate patients with headache should be alert to signs that suggest a serious underlying disorder. Missing a secondary headache disorder can have devastating consequences for the patient. The disorders that fall in this category include brain tumours, brain bleeds, brain infections.

Red flag signs

The presence of the following red flag signs in the context of headache could indicate a serious underlying disorder and warrants an urgent medical review: 

1. Headache with systemic symptoms including fever.
2. Headache in a patient with prior history of cancer.
3. Headache with clinical signs on examination including decreased consciousness.  
4. Onset of headache is sudden or abrupt ( i.e., headache peaks in intensity over few minutes rather than several minutes or hours).
5. New onset headache after age 50 years- this would be unusual for a primary headache disorder like migraine. 
6. Pattern change of usual headaches or recent onset of different type of headache. 
7. Positional headache i.e., headaches that worsen on lying flat or come on within few minutes of standing up. 
8. Headaches precipitated by sneezing, coughing, or exercise.
9. Headache with evidence of swelling behind the eye (papilledema) detected at the opticians.
10. Headache onset during pregnancy or following delivery.
11. Headache associated with a painful eye, eye swelling or with autonomic features like watering from the eye, redness of the eye, running nose. 
12. Headache that developed following head trauma,\.
13. Headache onset in the context of an immune deficiency state such as HIV.

Post-traumatic headache

Post-traumatic headache (PTH) is the most frequent symptom after mild traumatic brain injury (mTBI). It is estimated that annually 69 million suffer from TBI worldwide, mostly attributable to mTBI. In New Zealand it is estimated that up to 36,000 people suffer TBIs each year, of which 95% are mild. 

The leading causes of TBI in New Zealand are falls, mechanical forces, driving-related accidents and assaults. Just over 20% of all TBIs in New Zealand are sustained through sport-related activity.⁽⁷⁾ 

The underlying cause of PTH is not fully known. It is thought that mechanisms related to both migraine and traumatic brain injury (TBI) are implicated. These include impaired descending pain control networks in the brain, neurochemical changes, neuroinflammation, cortical spreading depression, and release of the pain protein- calcitonin gene-related peptide (CGRP).

The treatment would be determined by evaluation of the underlying headache phenotype. Common patterns of PTH include migraine type and tension type headache patterns. Part of the management also includes addressing if patients are overusing pain medications. 

Headaches may resolve within 3 months of the traumatic brain injury but in some patients this may last longer.  

References 

1. Collaborators GH. Global, regional, and national burden of migraine and tension-type headache, 1990-2016 – a systematic analysis for the Global burden of disease study 2016(external link) Lancet Neurol. 2018;17(11):954-76.
2. Goadsby PJ. Primary headache disorders– five new things(external link) Neurol Clin Pract. 2019;9(3):233-40.
3. Bose P, Goadsby PJ. The migraine postdrome(external link) Curr Opin Neurol. 2016;29(3):299-301.
4. Frederiksen HH, Lund NL, Barloese MC, Petersen AS, Jensen RH. Diagnostic delay of cluster headache: A cohort study from the Danish Cluster Headache Survey(external link) Cephalalgia. 2020;40(1):49-56.
5. Do TP, Remmers A, Schytz HW, Schankin C, Nelson SE, Obermann M, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list(external link) Neurology. 2019;92(3):134-44.

Webinar: Headache management and red flags through cases(external link) Dr Ray Bose, Neurologist

This presentation covers:

• Salient features of headache history taking
• Red flags
• Headache management
• Mixture of common and rare headache presentations

You can watch the video, answer questions and claim hours with a certificate. 

Managing common neurological conundrums

Professor Alan Barber presented on common CNS issues such as headache, seizures, turns and tremors through case-based learning to increase practitioner confidence in assessment and management.

(Goodfellow Unit Webinar, NZ, 2020)

PHARMAC seminars

1.  Video: Neurology basics - Dr Anna Ranta, part 1 (27 minutes)

(PHARMAC Seminars, NZ, 2019)

Video: Neurology basics - Dr Anna Ranta, part 2 (30 minutes)

(PHARMAC Seminars, NZ, 2019)

2. Video: Interactive cases 1, Dr Anna Ranta, part 1 (38 minutes)

(PHARMAC Seminars, NZ, 2019)

Video: Interactive cases 1, Dr Anna Ranta, part 2 (28 minutes)

(PHARMAC Seminars, NZ, 2019)

Video: Interactive cases 1, Dr Anna Ranta, part 1 (17 minutes)

(PHARMAC Seminars, NZ, 2019)

Neurology updates (6 videos)(external link) PHARMAC Seminar Series, March 2015

Headache topics