Introduction

Headache is the most common neurological condition for which consultation is sought.¹ The approach adopted in this review offers a clinical strategy to guide the family doctor without need to resort to the International Headache Society (IHS) classification.²

This should not be interpreted as undervaluing that classification,² which is pivotal in allowing international consensus necessary for clinical research and trials, but clinical trials do not necessarily reflect everyday practice. The IHS criteria² allow researchers around the world to recruit patients with rare headache diagnoses to trial novel treatments with the ability to recruit sufficient patients to achieve statistical power. While this is fundamental for scientific progress, it does little to assist the general practitioner who sees very few cases of such conditions; for example, cluster headache. Cluster headache was not randomly chosen for this example, but rather because it is diagnosed more often by family doctors than neurologists, and affects less than 1% of those with headaches.³

What follows is an idiosyncratic approach to headache management developed over years of clinical experience, rather than based purely on evidence-based medicine.

Broad-Brushed Clinical Approach

A practical, if unscientific, approach to headache is to consider that primary headaches lie on a continuum (see Fig 6.1). At one end of this continuum lies tension-type headaches, while at the other is migraine (with or without aura). In the middle is what might be called tension-vascular headache with features of both, a term excluded from the IHS classification.²

FIGURE 6.1 Headache continuum.

Differentiating tension-type headache from migraine

Most patients who present to the neurologist with ‘bad headaches’ automatically assume these are migraines. Migraine and ‘bad headache’ have become synonymous for patients, but doctors need to determine the type of headache to select the appropriate treatment.

This starts with a concise history dating from the onset of the headaches. The doctor needs to know: how long the patient has had headaches; where they occur in the head (unilateral, bilateral, frontal, occipital, vertex or completely generalised); the nature of the pain (be it constant and gripping, throbbing and pulsating, or stabbing and lancinating); associated features (visual symptoms, gastrointestinal (GI) symptoms of nausea and/or vomiting, photophobia, phonophobia or osmophobia); the frequency and duration; and precipitating and relieving factors. This will assist in differentiating migraine from tension-type headache (see Table 6.1).

TABLE 6.1 Differentiation between migraine and tension-type headaches

Migraine	Tension headache
Unilateral—often in the temple	Bilateral—like a band or in both temples
Throbbing pain—pulsating	Tight, gripping pain—constant
May be provoked by: • often occurs once stress has passed (let-down phase) • smells • foods (e.g. chocolate) • hormonal changes	May be provoked by times of maximal stress
May have: • teichopsia (zigzag bright shimmering colours) • fortification spectra (like seeing the top of a cowboy fortress) • see rainbow effects • see photons of light (bright flashes)	Either no visual symptoms or simply some blurring of vision
Nausea and vomiting is common	Nausea may be present but rarely vomiting
Commonly have: • photophobia • phonophobia • osmophobia • positive family history	Usually do NOT have: • photophobia • phonophobia • osmophobia • positive family history
Acute intervention: • triptans • ergots • occasionally early use of analgesics	Acute intervention: • rest • simple analgesia
Prophylaxis: • pizotifen offers effective prophylaxis	Prophylaxis: • tricyclic antidepressants (amitriptyline and imipramine offer effective prophylaxis)
May be provoked by alcohol	May be eased by alcohol