Chronic Headaches
Mr P appears distracted and strained as he hobbles into the assessment cubicle with his
wife saying “you’ve got to help me doc…I’m getting these headaches every day now and
they’re driving me nuts…I’m constantly taking Voltaren and those Panadeine Fortes and
they’re not doing anything ...There must be something going on…”.
You enquire about other pains and his wife tells you that he has had a shocking pain in his L)
foot and leg since his accident last year but the GP had checked this and says it’s all healed
ok. She volunteers that Mr P fractured his L) leg in three places in a trail bike accident 10
months ago and required a plate but “the headache is what’s killing him now”. They both
agree that “something has to be done” … and they aren’t going home until they get some
answers…
The first task of your assessment is diagnostic triage. In this case determining whether this is
a primary headache disorder or a secondary headache. A rapid search for red flags will
achieve this. It is also critical to establish early on why the patient has presented that day.
Despite the triage comment and opening statements appearing non-specific there is usually
a particular symptom or underlying concern that precipitates an ED attendance. This can
vary from something alarming such as acute visual disturbance or weakness to more prosaic
concerns such as employer/ spousal pressure and internet self-diagnosis site prompts. This
may take a little time to tease out but addressing what our American colleagues call the
presenting complaint will you over the line when the list of problems seems overwhelming.
Yellow Flags - Psychosocial features unrelated to the source of pain that have been shown
to have a significant impact on prognosis.
Belief that the pain is harmful or severely disabling and conflict at home or work have a
strong association with delayed recovery. A range of amplified pain behaviours can also be
considered yellow flags and, whilst indicative of psychosocial distress, do not constitute
malingering or hypochondriasis but it does indicate that successful management will require
a comprehensive plan beyond the scope of a single visit to the ED.
More insidious motivations such as drug seeking can be difficult to confidently detect and
may overlap with more organic concerns. The patient who is fixated on receiving opiate
analgesia as soon as possible is more likely to be waving a large yellow flag than a red one. A
dogmatic initial stance on this front will likely thwart an opportunity to engage, make a
meaningful assessment and suggest an appropriate management plan. Frank discussions are
more effective when coupled with some rapport.
Red flags in Headache:
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Sudden onset and extreme severity (sub arachnoid haemorrhage - SAH)
Fever
Exacerbation by coughing, straining, changes in posture or sneezing (raised
intracranial pressure – ICP)
Association with eye movements, visual field defects and blurred vision.
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Neurological symptoms – sensory changes, weakness, diplopia.
Ask early about prior headache assessment – GP and specialist consultations and
investigations.
Enquire about current and past management strategies.
History of malignancy
Jaw Claudication – (older patients)
Other Important History:
General pain questions:
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Type
Distribution
Duration - paroxysmal v fluctuant v constant
Pain score (0-10) at time of exam and worst and least that day.
Activity restriction such as sitting/ standing/ walking.
Sleep disturbance
Headache specific questions:
Precipitants – stress, alcohol, foods, (hormonal changes)
Associated features- visual disturbances such as teichopsia (zig zagging, bright shimmering
lights), fortification spectra (like the top of a fortress), rainbow effects and ‘photons’ (small
spots of bright light in visual field).
Photophobia/ phonophobia/ osmophobia
Mood and cognitive changes
Past history –pain syndromes, dental conditions, anxiety/ depression
Social History
Drugs/ alcohol
Examination:
General appearance – obesity/ cachexia
Vital signs
Eye exam and Fundoscopy – Visual field defects and raised intracranial pressure
Neurological exam – Particularly cranial nerves and gait.
Note: if there are no symptoms suggestive of lower motor neuron signs then it is not
necessary to perform a full peripheral limb neurological examination. Brief tests of muscle
power and coordination are useful more to distract the patient, inform impressions of affect
and fear of movement than elicit subtle neurological signs.
Other: In this case A has given a history of a persistently painful limb several months post a
fracture. Expose and examine this area for wasting, skin changes, infection and thrombosis.
Test neurovascular status of this area carefully.
The Lowdown on headaches:
Chronic or persistent headache technically requires headache to be present ≥15days per
month and ≥4hrs/ day over the preceding 6/12 however most patients and GPs practical
definition is based on a much lower frequency and many patients call bad headaches
migraines despite a clinical picture more suggestive of TTH.
The distinction is not always obvious. Some prefer to consider TTH and migraine as a
spectrum while others consider them two distinct entities. More recently a third category
Tension-Vascular Headache (TVH) has been defined.1i
Considering the headache type does help inform management decisions.
Tension Type Headache (TTH) - Extremely common and generally not disabling but pain can
be severe...It is likely to be bilateral and is commonly described as tight, gripping pain or a
band-like pressure. Occasionally visual blurring is described.
Cervicogenic Headache – These headaches are thought to arise from the spinal trigeminal
nucleus but are clinically indistinguishable from TTH and mostly respond to the same
treatments.
Migraine - Intense pain plus nausea and/or photophobia – lasting >4/24
Often unilateral and may be retro-orbital.
Comorbid mood +/- anxiety disorders common.
Childhood variant = recurrent central abdominal pain (non colicky).
A normal neurological exam and attack free intervals are required to confirm the diagnosis.
Analgesic overuse headache - Cited as the third most common cause of headache. This is
the more long term end of a spectrum of medication related headaches and applies to
patients who have been taking analgesics regularly for long periods.
Suggestive features:
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1
Refractory daily headache (or most days).
Strong association with distress and irritability.
Frequent use of triptans and ergots associated with cold extremities, palpitations,
myalgia and/ or paraesthesia.
Daily use for several days or frequent use (e.g. more than 15 days per month.) of
immediate relief medications.
Headache Classification Committee of the International Headache Society. The International Classification of
Headache Disorders (3rd Ed). Cephalgia. 2013; 339:629-808
Similar conditions include withdrawal headache and analgesia rebound headache. Another
feature of analgesia overuse is that it renders headache prophylaxis ineffective.
Drugs shown in observational studies to have a strong association include Codeine (and
other opiates), Triptans – (particularly if more than 12 doses per month) and Ergotamine2.
Drug withdrawal generally results in resolution of headache3 but requires a motivated and
well supported patient.
Cluster Headache - A rare and specific form of headache – Generally a distinctive precursor
such as alcohol ingestion is elicited.
Severe unilateral headaches with autonomic features – ptosis, lacrimation, conjunctival
injection. There may be eyelid oedema, meiosis and ptosis.
Typically occur in the morning.
Other conditions:
Sinusitis – Maxillary or frontal pain with associated nasal discharge, obstruction, night
cough, decreases smell, fetor, +/- fever.
Trigeminal Neuralgia (>40yo) – Often secondary to inflammation or vascular compression at
the nerve root but secondary causes are found in 15% (tumours, MS, skull base
abnormalities. Carbamazepine is effective. Commence at low dose e.g. 100mg BD increasing
100mg every 3-4 days until pain controlled.
TMJ dysfunction
Dental Pathology
Imaging (CT and MRI):
Not if – recurrent headaches characterised by consistent features. Absent red flags on
history or examination.
Consider if new focal neurological sign(s), changes in character or pattern, new onset severe
headaches, seizures, a history of neurocutaneous syndromes (e.g., neurofibromatosis,
tuberous sclerosis or Sturge-Weber syndrome) or location is purely occipital. MRI is the
modality of choice in most instances.
Blood Tests:
Rarely helpful but may be indicated based on specific findings of history or examination
2
3
http://www.medscape.com/viewarticle/429667_1
Paemeleire K, Crevits L, Goadsley PJ, Kaube H. Practical management of medication overuse headache. BMJ
2008, 336:88-92
Management:
Communicating with patients about persistent or chronic pain is best approached by
formulating the problem in terms of the many contributors rather than attempting to
reduce it to a specific pathophysiological process.
Diclofenac, Ibuprofen or Naproxen combined with paracetamol will provide good relief for
TTH in most instances.
Tricyclic Antidepressants (Amitriptyline or Imipramine commencing at a low dose) have
been shown to provide effective prophylaxis when frequency is unacceptable and may be
considered.
Migraines respond to early simple analgesia as for TTH but also however escalation to
Triptans or Ergots may be required. Prophylaxis is via Pizotifen (commenced at a low dose
0.5mg BD).
All forms of prophylaxis require gradual upward titration so start low and refer back to the
GP.
Other options such as Sodium Valproate, Gabapentin and Pregabalin have some (limited)
evidence for efficacy in persistent headache. Botulinum Toxin also has an evolving role.
Neurology input should be sought if considering any of these agents.
Optimising medication is certainly worthwhile but unlikely to solve the problem alone.
Reunite the patient with their GP with the added benefit of your supportive observations.
Providing only increased doses of analgesics makes the GPs already challenging job even
more difficult.
Nutraceuticals such as Magnesium, Riboflavin and Co-enzyme Q10 have been studied in few
small RCTs with no superiority over placebo shown.
Very important lifestyle concerns are:
Optimising hydration, sleep hygiene and exercise is important.
Ensuring regular healthy meals plus mid-morning and mid-afternoon snacks4.
A General Rant on Pain and Analgesia:
Research has revealed some of the multiple mechanisms at play in causing pain, and
multimodal therapeutics tend to reflect this complex neurobiology.5
4
5
Ivan Lopez J, Kabbouche M. Paediatric and Adolescent Migraine Headache 2012; 52:1451-3
Gilron I, Jensen TS, Dickenson AH. Combination pharmacotherapy for management of chronic pain: from
bench to bedside. Lancet Neurol 2013; 12: 1084-1095.
There is strong emphasis on neuroplasticity, particularly central sensitisation, with the
growing realisation that central changes generate pain long after peripheral nociceptive
stimuli have waned or disappeared altogether (hence the name change from “chronic” to
“persistent” pain).
Opioids have fairly clear roles in both severe acute pain management however longer-term
opioid monotherapy is discouraged in most patient populations, in favour of multimodal
strategies, and indications for the use of opioids have been tightened because of
widespread misuse, dependence and diversion.6
In a world that expects quick fixes for everything, expectations and capacity for medical
amelioration of pain often far exceed reality. 7
Pain clinics can only see a small fraction of patients who have pain; medication and
procedures often do not cure the pain; and increasingly disgruntled patients shop around,
often favouring medication over other harder but ultimately more rewarding strategies.
Physiotherapists and psychologists work with patients’ natural defensive mechanisms that
lead to fear of movement and activity, and help to engender healthy pacing of activity and
rebuild confidence that life is possible without pain being a barrier to everything.8 Check out
this great educational video hat explains this interaction:
http://www.youtube.com/watch?v=4b8oB757DKc
Australia's National Pain Strategy describes three points in the current model of care where
sufferers of chronic pain (defined as constant pain on a daily basis for 3 months or more in
the past 6 months) encounter “fault lines” or disruptions in their treatment journey. The
first of these is the prolonged cycle of tests, medicinal therapy and referrals that occurs with
the result being a delay to effective treatment.9
6
National Drug and Alcohol Research Centre. A review of opioid prescribing in Tasmania: a blueprint for the
future. Sydney: University of New South Wales, 2012.
7
Hogg MN, Gibson S, Helou A, et al. Waiting in pain: a systematic investigation into the provision of persistent
pain services in Australia. Med J Aust 2012; 196: 386-390.
8
GP Access and Hunter Integrated Pain Service. Understanding pain: what to do about it in less than five
minutes?
http://www.youtube.com/watch?v=4b8oB757DKc
9
Australian Pain Management Association. National pain strategy: pain management for all Australians.
Sydney: Australian Pain Management Association, 2010
Case conclusion:
Your history revealed a dull bilateral headache which came on soon after waking and
persisting until mid-morning.
A has been consistently taking 10-12 Panadeine Forte tablets daily for pain. He is a selfemployed carpenter and has worked intermittently in the last 4 months after 3 months of
no work. He has used up his savings and sold a ski boat and to pay living expenses during
this time. He admits to drinking alcohol (spirits – Rum) to help with pain management in the
initial 2 months but found this did not help and has drunk very little in the preceding 3
months
Mr Pain’s vital signs and neurological examination are unremarkable.
His left foot and ankle are mildly atrophic, erythematous and slightly warmer than the right
with several healed surgical scars. Strength with ankle extension and, to a lesser degree
flexion, appear reduced. There is no calf swelling or tenderness but you note hyperalgesia
all over the foot and ankle. Testing sensation is intolerable.
You ask the ED physiotherapist to review these findings. After careful review opinion is the
patient is likely suffering from a Complex Regional Pain Syndrome (CRPS). She is concerned
about signs of early contracture formation and plans to arrange regular follow-up through
the hospital’s affiliated community physiotherapy service.
You are also concerned the headache is associated with analgesic overuse.
A discussion with the patient ensues regarding the persistent limb pain and possible
contributors to his headaches including frequent codeine use. You prescribe Amitriptyline
(evening dose) as a trial. (The gabapentinoids Gabapentin and Pregabalin are also useful but
the lack of PBS listing was cost prohibitive). Slow Release Naproxen and Tramadol had
worked previously and were also prescribed. Given the complexity of this case you refer to
the complex pain clinic before sipping at that stone cold coffee your colleague dropped on
your desk 2 hours ago. Unexcited by the prospect of documenting the subtleties of this
encounter you glance hopefully at the screen once more.
“56yo F c/o dizziness. Intermittent 4/12. “… Perhaps it’s time for a fresh brew…