Management of headache patients

Headache is a very common complaint, in both primary care and in specialist settings. Headache patients account for around 20% of all outpatients seen in neurological practices and their management, particularly when they present with intractable headache, or are suspected of having secondary headaches, can be a challenge for the clinician. All the guidelines agree that the diagnosis of headache is merely clinical and that testing is not recommended if the individual is not significantly more likely than anyone else in the general population to have a significant abnormality. A full history of the temporal profile of the headache should be gathered first: when it first started, the circumstances of its onset, whether it has remained the same over time, and, if not, in what way it has changed. The patient should be questioned carefully about the specific characteristics of the attacks (frequency, duration, severity of the pain, efficacy of the treatments). It is also necessary to establish whether there is a history of other diseases and to investigate gynecological and psychological history, and family history. History alone allows a diagnosis of probable primary headache. Signs of a possible secondary headache must be carefully sought in all patients, even in apparently clear-cut cases. The guidelines recommend careful investigation of new headaches or those whose features have recently changed in order to exclude secondary headache. Once a secondary headache has been reasonably ruled out, it can help the patient to investigate possible comorbid pathologies and suggest appropriate lifestyle changes.