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Several large studies have found that nearly 90 per cent of the general population have had at least one headache in the previous year. It is certainly the most common reason for which patients are referred by their GPs to neurological outpatient clinics. Chronic headaches constitute a range of disabling conditions that affect about 5% of the adult population, and about 2% of children. For the Brain and Spine Foundation, UK's only generic neurological charity offering advice and support for professionals and patients across the spectrum of neurological conditions, working with the RCGP on developing a Headache in Primary Care course was a welcome opportunity to help update GPs on one of the most dynamic areas in neurology.

Headache as a symptom accounts for the majority of the 4,000 calls to the Brain and Spine Helpline each year. Direct interest in other headache-related information services (in the form of printed bound booklets, downloadable pdfs, and website hits) adds up to over 60,000. And this does not account for other titles the Foundation produces in which headache features as a symptom. These include Brain Tumour, Sub-arachnoid haemorrhage, and Back and Neck Pain.

As well as dealing with the information needs of patients and their carers, the Brain and Spine Foundation also supports healthcare professionals in their diagnosis and treatment of conditions like headache. Approximately 12 per cent of annual Helpline enquiries come from professionals (community nurses, social workers, occupational therapists), most of whom represent multi-disciplinary teams working in the community.

Professional perspective
The field of headache has changed dramatically in the past five years in terms of diagnosis, treatment and ongoing management. Advances in imaging techniques, the development of more effective drug therapies (both curative and preventative), and even surgery have all contributed to progress in this area.

Although a specialist subject, it is hugely diverse with GPs having to differentiate between tension headaches, migraine, cluster headache, medication overuse headache, and several other chronic headache subtypes. So despite the aforementioned advances, this diversity can present a challenge to GPs to diagnose accurately and therefore treat effectively – or indeed refer to a specialist if a sinister headache is suspected.

The past five years has also seen the implementation of more headache services in the UK. Most neurological units in hospitals now have headache specialist clinics dealing with chronic headaches and more complicated migraine.

According to Angela Collett, neuroscience nurse and Helpline Manager at the Brain and Spine Foundation, “Our experience from callers suggests that a proportion GPs are very good at supporting patients and identifying one-off severe headaches like those associated with a vascular malformation or sub-arachnoid haemorrhage, however we do receive reports from people whose symptoms have been dismissed or overlooked by their GPs, including those with a subsequent diagnosis of brain tumour or other serious conditions. GPs can also be unsure about what to do with patients who have gone round and round the houses with chronic headache but not found sustained relief from any of the therapies prescribed. Many GPs are unaware of the headache specialist clinics.” She continues, “The RCGP Headache in Primary Care course is an excellent opportunity for GPs to be updated on the more complicated chronic presentations which can be difficult to treat.”

Scores and scores of callers to the Helpline discuss at length the devastating effect of headache. Although generally harmless in themselves, chronic headache can take over a person’s life. As well as the physically debilitating effect (we have all heard of migraine sufferers taking to their beds for two days), the psychological impact on wellbeing is often underestimated. In many cases a headache can be made worse by worrying about what might be causing it, and in this case medical reassurance is often all that is needed.

Callers to the Helpline are generally asked:

• Whether they’ve consulted their GP.
• Whether the headache is caused by an injury.
• Whether they would consider a complementary therapy in addition to drug treatment. For example, osteopathy if the headache is due to wear and tear of the neck joints.
• To go back and ask their GP to refer them to a neurologist or specialist headache clinic.

When to refer
There are a number of rare but potentially serious causes of headache which have to be ruled out whenever someone complaining of headache seeks medical advice. Referral to specialist neurology or headache services may be necessary when:

• A sinister headache is suspected.
• The diagnosis does not clearly identify patients with chronic migraine, chronic TTH or cluster headache.
• The patient is refractory to repeated acute and / or drug treatment.
• The frequency of the patient’s headaches increases, despite intervention.

Information is important
Meeting the information needs of people with neurological conditions and the professionals who treat them, is at the heart of what we do. Consequently helping the RCGP develop a course on headache seemed an appropriate and effective way of keeping members up-to-date with latest developments in this specialist area and encouraging best practice.

Headache in Primary Care is the latest in the RCGP Learning Unit’s series of interactive short courses for GPs and Primary Care Professionals. It is an ideal learning resource providing access to small packages of information allowing users to cover clinical conditions quickly, when they have available time. It will develop clinical skills, help in the diagnosis and management of common headaches, identification of serious causes of headaches and cover team working and service provision. Primary & secondary headache areas include:

• Migraine
• Tension-type headache
• Cluster headaches and other TACs
• Subarachnoid haemorrhage
• Intracranial tumor
• Idiopathathic intracranial hypertension
• Giant cell arteritis
• Cerebral venous sinus thrombosis