GP Specialist Dr. David Kernick explains the fundamentals of remote consulting to treat headaches.
Headache is a medical area which is a good candidate for remote consultation. After more than 20 years within a clinic for headaches I can’t remember a single incident where I’ve changed my treatment due to a clinical exam. A thorough history is essential and the most important aspects of good treatment are:
- Blood pressure (to rule out malignant hypertension) and fundoscopy upon presentation.
- Inflammatory markers that are appropriate for those who are over 50 , to determine temporal arteritis.
These issues can be addressed online: most people have access to personal monitoring of blood pressure. Although fundoscopy is a necessary part of the routine of a GP however, extremely accurate assessments can be done by an optician. There is evidence that headache consultations provide the same outcomes, whether in person or remotely. 1,2
So, even though surveys show that about a third of patients prefer face-to-face sessions, three GPs are able to manage the initial consultation via phone or video for those willing to meet remotely.
As presentation becomes more complicated especially for chronic migraine that is connected to a range of comorbidities, face-toface consultations are the best way to identify subtle signs and improving communication and gathering of information.
The three goals of management of headaches are the following: eliminate headaches that require immediate attention, identify the ones that require urgent attention as well as determine and treat the cause of headache.
The most important pointers in the past
- Why is the patient contacting this moment? What are the root causes? Although a tumor in the brain is not common however, it is a constant issue for both the patient and physician.
- What types of headaches does the patient suffer from? In most cases, patients will experience various types of headache. If one of them is migraine, all the others will likely be an element of a migraine spectrum.
- Are the headaches getting worse? A headache that gets worse suggests an underlying condition.
- What impact do headaches can have on the patient’s overall quality of life both between and during attacks? This could be a broader inquiry that improves the quality of consultations.
- Family family history. It is common to have an ancestral migraine history in migraineurs.
- What is the patient’s routine in the midst of a headache? The sufferer of migraine may want to rest in a quiet, dark room those suffering from cluster headaches will pace around the space and feel agitated. tension headaches will have little impact on activities.
- How often do they consume painkillers? It is crucial to rule out headaches caused by medication use. This is the case if for three months or more patients are taking painkillers for more than 15 days in a month, or triptans for more than 10 days.
- Are there triggers or alleviating elements? The relief from lying down could be a sign of a headache with low pressure because of a lower CSF pressure.
- A history of medical conditions is essential. There are a variety of comorbidities that can be associated with migraine, with a particular focus on depression, anxiety sleep disorder, other painful conditions like the irritable bowel syndrome as well as the fibromyalgia.
Which are the top commonly used diagnoses?
Migraine is one of the more likely diagnoses for primary care, and most cases of headaches that are tension-related will likely be migraine-like in the sense that they are migrainous in.
Table 1 provides the estimated diagnoses rates as a proportion of all headaches presented to primary care, as derived from research. Anyone who experiences a headache that is new that is over 50 is a sign to suspect temporal arteritis.
Table 1. Estimated diagnose rates for primary care (4,5)
Diagnosis ( percent of headaches)
- Migraine (73 percent)
- Other primary headaches typically tension type headache with cluster headaches of 1 percentage (23 percent)
- Primary tumor (0.09 percent)
- Subarachnoid haemorrhage (0.05%)
- Meningitis (0.02%))
- Temporal arteritis (0.02%)
Stories that need immediate attention
- Thunderclap headache is a intense headache that reaches its highest level in just one minute. It can be caused by a variety of factors including subarachnoid haemorrhage as the most likely cause.
- Headache that is associated with visual disturbances or tinnitus is common for obese young women. Idiopathic intracranial Hypertension must be ruled out using fundoscopy. A normal fundoscopy does not rule out this diagnosis but an ophthalmic retinal examination is always beneficial. Papilloedema is always a need for immediate evaluation.
- New headaches in patients more than 50 years. Examine inflammatory markers, or if none are readily available and suspicions are elevated that there is a temporal arteritis (tender or non-pulsatile temporal arterial or chronically unwell) begin taking steroids.
- Other factors to consider include meningitis as well as carbon monoxide poisoning.
Histories that could need immediate attention
- Cluster headache. While the cause isn’t life-threatening, the condition is possibly the most painful condition and is often called a’suicide headache’ due to sufferers dying when experiencing or anticipating an attack. It is essential to not delay the diagnosis. The pain is not as severe as migraine, is always periorbital, and unilateral, accompanied by autonomic symptoms to the opposite side (ask your patient record an audio recording) as well as the patient seems unrestful and anxious.
- Headaches that are triggered (not caused) through exertion, whether by exercise or manoeuvres of the Valsalva type. It is possible to have the chance of having being a pathological condition, whether the space-occupying lesions or Chiari malformation.
- Headaches that could be a sign of an tumor that is underlying. Particularly, cancer of prostate, breast or lung may be a cause for concern in secondary. Other signs to be concerned include headaches and other neurological symptoms or signs, headaches in older people as well as seizures, memory loss or personality changes.
- Headaches that awaken the patient from sleep may be the result of the presence of a higher intracranial pressure however migraines and clusters of headaches can also wake patients. Headaches that have a dramatic shift in their pattern could be reason to be concerned, however experts are required to recognize abnormal patterns, specifically with migraine.
Histories that need regular management
- About 95% of headaches are primary. Migraine is most frequent, and 30% of them will have aura. A headache that occurs frequently and is accompanied by an increase in sensation, especially sensitive to sound, light or movement could be migraine. About 5% of patients suffer from chronic migraines, defined as headaches that last for 15 or more days of the month, and of these 8 days are migraine. Chronic migraine is accompanied by an enormous burden of anxiety, multimorbidity and depression.
- A tension headache may be described as dull non-featureless, bilateral headache that is often associated with migraine. In many instances tension-type headaches can be part of a migraine spectrum.
NICE guideline CG150 gives evidence-based advice on diagnosis and assessment. 6
Neurological examinations conducted remotely
While examinations are rarely a contributing factor to the management process There are some indications which can be evaluated with an online consultation. A close observation of neck movement could help to identify an underlying headache. The patient could trigger the temporal artery to tenderness, if it is present. A video on the signs of neurological disorders remotely is accessible at the American Headache Society website. 7
To treat acute migraines, the prokinetic can be effective due to gastric stasis. Analgesia that is simple, like an NSAID and a triptan may be prescribed to treat the discomfort. Be aware that the failure to feel a response to a triptan does not constitute an effect of class. If you need to prevent it an topiramate, amitriptyline or ss-blocker are the medications of first option.
Amitriptyline can be helpful in tension headaches.
The possibility of medication-related headache must be considered at all times. In other situations, the treatment will be based on the diagnostics. 6
“Dr David Kernick is a GPSI for headaches in Exeter Headache Clinic. Exeter Headache Clinic
- Bekkelund S and Muller K. Video consultations with a psychiatrist in the case of headaches caused by overuse. A controlled study that was randomized. The Brain and Behav 2019;9:e01344
- Bekkelund S and Muller K. Remission rates for one year for chronic headache when comparing face-to face and video consultations with neurologists: a controlled, randomized study. Journal Medical Internet Res 2021;23:e30151
- Dias L et al. Teleconsultation for Headache in the era of Covid-19: Assessment of patients and possible directions. Eur J Neurol 2021;28:3798-804
- Tepper S et al. Prevalence and diagnosis of headache for patients who consult with their doctor with complaints of headache: results obtained from Landmark Study. Headache 2004;44:856-64
- Kernick D et al. What happens to headaches that have just onset brought to primary treatment? A case-cohort research using electronic records of primary care. Cephalalgia 2008, 28:1188-95.
- NICE CCG150. Headaches in adults over 12 years old Headaches: management and diagnosis. 2021. Link
- Roblee J. Facebook Live Conducting a telemedicine neurological exam. American Headache Society 2020. Link
A range of management plans and patient information sheets can be found at exeterheadacheclinic.org.uk
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