Clinical update: headache assessment and treatment approaches

Many of us struggle with the diagnostic challenges headache patients present. This group needs careful history taking, an understanding of the pathophysiology of headache conditions and liaison with medical colleagues when secondary pathology is suspected or the diagnosis is unclear. This update looks at key headache features physiotherapists are likely to see and makes suggestions for assessment and treatment. It is important when treating patients with headache to be familiar with the NICE and British Association for the Study of Headache (BASH) guidelines, which give clear diagnostic criteria, red flag features and management guidelines. 

Diagnosis

The International Headache classification divides headaches into three categories. The majority are primary headaches, in that they are not caused by another disorder. Migraine is the most common and disabling of these and has a cumulative lifetime risk of 43 per cent in women and 18 per cent in men, generally affecting those of working age. It is second only to back pain in years lost to disability. It is characterised by nausea, photophobia and/or phonophobia with moderate to severe pain, lasting between four and 72 hours when episodic. 

Just one to two per cent of patients with migraine develop chronic symptoms each year, often losing the characteristic migraine features, leaving near constant and severe pain. Only 20 per cent of patients with migraine experience aura, which maybe visual, sensory or motor, lasting five to 60 minutes, normally preceding the headache. The most likely diagnosis of a patient with an intermittent and disabling headache without neurological signs is migraine.  Tension Type Headache (TTH) is a milder, bilateral, non-throbbing primary headache without migrainous features.

Many secondary headaches are caused by another disorder. Cervicogenic headache (CGH) is one of these with a prevalence of 0.17 per cent – 4.1 per cent ^[1,2]. CGH patients are often referred to physiotherapy because they have neck pain with headache.  Without clear provocative cervical movements causing headache, the cervical spine is unlikely to be the cause. Patients with more common headaches such as migraine or TTH have a significantly higher one-year prevalence of neck pain^[3]  with headache, leading to over diagnosis of CGH. Migraine studies show that there is a coupling of the nociceptive inputs from the cervical spine with dural afferents into the trigemino-cervical complex explaining the high co-occurrence of neck pain with other headache diagnoses ^[4]. It is important that physiotherapists are aware of these differential diagnoses when assessing and planning treatment. Migraine in women can be triggered by menstruation, for instance, giving an added reason for symptom provocation that may not have been considered if the diagnosis was thought to be CGH.

Other secondary headaches such as Medication Overuse Headache (MOH) occur in one to two per cent of the general population but in up to 50 per cent of headache referrals ^[5].  MOH occurs with analgesia overuse in headache-susceptible individuals, such as those with migraine or TTH, resulting in a constant, severe headache. Headaches due to vascular pathology such as subarachnoid headaches or cervical artery dissection, while extremely rare, can cause major morbidity and mortality. National guidelines give clear management plans about assessment and treatment. The third category, Painful Cranial Neuropathies and facial pain are not normally seen in physiotherapy.

History and treatment

A good history and a headache diary are vital. The suggested questions (see box) aim to draw out information in the most succinct way, with notes on the relevance of typical responses. Headaches that do not match diagnostic criteria should be discussed with the patient’s GP. 

Headache patients have been successfully treated with manual therapy for many years but benefit from a wider range of physiotherapy skills too. Physiotherapists can help through NICE recommended acupuncture for migraine and TTH, as well as running education through self-management groups. Advanced practice roles where injections /drug management are interspersed with pacing back to healthier lifestyles are also part of the physiotherapist’s work with this highly disabled and often invisible group of patients. 

• Anne-Marie Logan MSc MMACP MCSP is an advanced practice physiotherapist at St George’s University Hospitals NHS Trust, London 

Taking a history

• Timing: How long does the headache take to reach maximum? Migraine develops over 20 mins+, Secondary headaches < five minutes to max intensity
• Duration: How long does the headache last? Migraine tends to be shorter than CGH. Chronic migraine has a constant background headache with bursts of severe headache on top, Trigeminal Autonomic Cephalalgia (TACs) such as cluster headache are shorter 
• Pain-free days: Do you have any days when your head feels crystal clear? Constant headache over months should alert you to questioning about analgesia use. Patients using NSAIDs/paracetamol            on ≥ 15 days/ month or triptans/ opiates   on ≥ 10 days/ month should see their GP about possible MOH
• Triggers: Can you bring a headache on? Cervical spine movement reproduces patient’s headache (CGH), Menstruation, hunger, alcohol (migraine)
• Location: Where is your headache? CGH is normally unilateral. Migraine is often worse on one side but spreads to both. TACS are unilateral
• Associated features: Does your face look different when you have a headache?  (1). When you have a headache what would you prefer to do? (2). When the headache is bad
• Would you prefer to turn the lights down?
• Would you prefer that everything was quieter?
• How does your stomach feel?  You are looking for autonomic features such as ptosis, miosis, lacrimation here. Migraine can have up to two of these features, CGH rarely have them. TACs have two or more autonomic symptoms. A preference for resting, photophobia, phonophobia and nausea, even if mild, are all migraine characteristics

References

¹Sjaastad, O and LS Bakketeig, Prevalence of cervicogenic headache: Vågå study of headache epidemiology. Acta Neurologica Scandinavica, 2008. 117(3): 
p 173-180; ² Knackstedt, H et al, Cervicogenic headache in the general population: The Akershus study of chronic headache. Cephalalgia, 2010. 30(12): p 1468-1476; ³ Ashina, S, et al, Prevalence of neck pain in migraine and tension-type headache: A population study. Cephalalgia, 2015. 35(3): p 211-219; ⁴ Bartsch, T, Migraine and the neck: New insights from basic data. Current Pain and Headache Reports, 2005. 9(3): p 191-196;⁵ Munksgaard, SB and RH Jensen, Medication Overuse Headache. Headache: The Journal of Head and Face Pain, 2014. 54(7): p 1251-1257