Headaches

Headache is a common symptom of many underlying diseases, e.g. malignancy, or state of health, e.g. dehydration, as well as a diagnosis in its own right, e.g. primary headache of an unknown cause (National Institute for Health and Care Excellence (NICE), 2022). Headaches can also be a symptom of how someone is feeling, their mental state, and as such headaches can be complex to diagnose and treat.

Despite the World Health Organisation (WHO, 2016) identifying headaches as potentially disabling for some people, headaches are sometimes not viewed seriously by healthcare professionals as they are common and can vary in severity. Headaches are one of the most prevalent and disabling of all disorders (Stovner et al, 2018) with a migraine or tension-type headache estimated to affect around 3 billion people worldwide in 2016. The most affected group is women in the 15–49-year-old age range (Stovner et al, 2018).

Headaches can:

• be experienced in a variety of ways
• be of varying degrees of intensity
• affect different parts of the head
• be of different types
• last for different lengths of time
• be associated with no, or many, other signs and symptoms (The International Headache Society, 2021; NICE, 2022).

During diagnosis healthcare professionals should ask about the location and spread of the headache as well as its severity, nature and quality (NICE, 2022). It is often useful for patients to keep a symptom diary so that nurses can better understand the potential causative factors for the headaches as well as the characteristics of the pain (Bandarian-Balooch et al, 2017). An individual may have more than one headache type and therefore diagnosis may be improved by maintaining a comprehensive headache diary (The International Headache Society, 2021).

By gathering information about the nature of the headache, the nurse or other healthcare professional, may

The International Headache Society (2021) classifies headaches into three main groups in its International Classification of Headache Disorders (ICHD-3):

• primary headaches including:
• migraine
• tension-type headache
• trigeminal autonomic cephalalgias
• other primary headaches
• secondary headaches
• trauma or injury related
• cranial or cervical vascular disorder
• non-vascular cranial disorder
• substance use or withdrawal
• infection
• disorders of homeostasis
• disorders of the head or other facial or cervical structures, e.g. eyes, teeth
• related to a psychiatric disorder
• neuropathies and facial pains and other headaches
• lesions of the cranial nerves or facial pain
• other

There are multiple aetiologies of headaches, so careful diagnosis is needed to rule out causes – which may be life threatening, e.g. intracranial tumours – or which are entirely reversible, e.g. sinusitis (Ahmed, 2012).

The first step in any diagnosis of a headache is to exclude the presence of a secondary headache which, while rare (Steiner et al, 2019), may be associated with a serious disorder often requiring immediate specialist referral and treatment. Key examples are sudden onset headaches which reach peak intensity within 5 minutes, thunderclap headaches, which may indicate an intracranial haemorrhage, while fever, altered consciousness, seizure, neck stiffness, or photophobia may indicate an infection in the central nervous system such as meningitis (NICE, 2022).

Other concerning symptoms include:

• progressive headaches which have changed drastically
• fever
• altered states of consciousness
• papilloedema
• new neurological deficit
• atypical aura
• motor weakness
• dizziness
• visual disturbance
• vomiting (NICE, 2022)

Some symptoms may arise because of the mechanism of injury or in the presence of other diseases. These include:

• recent head trauma
• headache associated with:
• coughing
• sneezing
• the Valsalva manoeuvre
• standing
• lying down
• headaches associated with other

The management of headaches depends on what is causing the pain. The best way to manage some headaches may be by preventing them from occurring in the first place, for example staying better hydrated during exercise (Arca and Singh, 2021) or visiting the optician for an eye test (Heus et al, 2018). Other causes of headaches may need the cause to be removed and require far more radical management, e.g. surgery to remove an intracranial tumour.

NICE (2021) highlight the need for reassurance and support for people affected by headaches, especially those where a secondary diagnosis has been excluded. Some people find it hard to accept headaches as a diagnosis; such individuals need to be reassured that primary headache is a genuine disorder. NICE (2021) identify that people affected by primary headaches may need to be given information about this as well as the support organisations that are available to

References

Ahmed F. Headache disorders: differentiating and managing the common subtypes. Br J Pain. 2012; 6(3):124-32. https://doi.org/10.1177/2049463712459691

Arca KN, Halker Singh RB. Dehydration and headache. Curr Pain Headache Rep. 2021; 25(8):56. https://doi.org/10.1007/s11916-021-00966-z

Bandarian-Balooch S, Martin PR, McNally B et al. Electronic-diary for recording headaches, triggers, and medication use: development and evaluation. Headache. 2017;57(10):1551-1569. https://doi.org/10.1111/head.13184

Chinthapalli K, Logan AM, Raj R, Nirmalananthan N. Assessment of acute headache in adults - what the general physician needs to know. Clin Med (Lond). 2018;18(5):422-427. https://doi.org/10.7861/clinmedicine.18-5-422

Christiansen S, Jürgens TP, Klinger R. Outpatient combined group and individual cognitive–behavioral treatment for patients with migraine and tension-type headache in a routine clinical setting. Headache. 2015; 55(8):1072-1091. https://doi.org/10.1111/head.12626

Herranz-Gómez A, García-Pascual I, Montero-Iniesta P et al. Effectiveness of exercise and manual therapy as treatment for patients with migraine, tension-type headache or cervicogenic headache: An umbrella and mapping review with meta-meta-analysis. Appl Sci. 2021;11(15):6856. https://doi.org/10.3390/app11156856

Heus P, Verbeek JH,