Your FMEP Guide to Headaches

You are writing your CCFP exam. You are presented with a patient with a headache. Do you know what to do? What to ask? What your management should be? If you know all the answers – well done. 

If not, keep reading – we have reviewed and summarized an excellent article by the Canadian Family Physicians to help you while you are studying.

Some things to remember about headaches…

• Rule out secondary headaches when diagnosing primary headache disorders
• Does the patient have recurrent migraine symptoms and normal neurological exam findings with no red flags on their history? If so, neuroimaging is likely not needed
• Remember that migraines are the MOST common type of headache – they are underdiagnosed and undertreated (so have this on your differential!)
• On a SOO, get patients involved in their headache management by asking them to keep headache diaries, adjust lifestyle factors, and manage stress

What information should you gather on a SOO about patients presenting with a headache?

• Onset, history, duration, and frequency of attacks
• Location of pain
• Associated symptoms
• Precipitating factors
• Severity and effect on activities (FIFE)
• Medications tried, results, and side effects
• Coexistent conditions that could affect treatment plan

On a SAMP, what are some physical exam maneuvers you could consider?

• Blood pressure
• Screening neurological exam
• If indicated, focused neurological exam 
• Neck examination
• Examination for temporomandibular disorders (if indicated)

“Doc, is this a migraine?â€

Does the patient tell you that they have at least two of the following symptoms** during the attack?

• Nausea/vomiting
• Photosensitivity/phonophobia 
• Worse with physical activity

** As per CFP article, but not exhaustive.

 If so, diagnose migraine with or without aura.

Does the patient experience headaches on ≥ 15 days/month for > 3 months? Do their headaches meet the above criteria for migraine? Do their attacks respond quickly to migraine medications on≥ 8 days/month?

If so, diagnose chronic migraine.

On a SOO, what’s your management plan?

• Use acute medications for individual attacks
• Use prophylactic medications if…
  • attacks are causing considerable disability (despite acute therapy);
  • acute medications are being taken ≥10 days/month (for triptans, ergots, opioids, and combination analgesics) or ≥ 15 days/month (for acetaminophen and NSAIDs); or
    
  • the patient is having recurrent attacks with prolonged aura, and/or the patient cannot be treated by acute medication due to contraindications
• Evaluate and treat coexisting disorders

“Doc, is this a tension headache?â€

Do the patient’s attacks include at least two of the following symptoms but no nausea?

• Bilateral
• Non-pulsating pain
• Mild to moderate pain
• Headache not worsened by movement

If so, diagnose tension-type headache.

Do attacks meet the above criteria and occur on ≥ 15 days/month for > 3 months?

If so, diagnose chronic tension-type headache.

• Treat with acute medication or with prophylactic medication (if indicated)

“Doc, is this a cluster headache?â€

 Does the patient tell you their attacks meet all of the following criteria?

• Frequent and severe
• Brief (< 3 hours)
• Unilateral (always the same side!)
• Ipsilateral conjunctival infection, tearing, or restlessness during attacks

If so, diagnose cluster headache (or another trigeminal autonomic cephalalgia).

• Treat with acute or prophylactic medication depending on frequency of attacks
• Neurology referral 

“Doc, is this a medication-overuse headache?â€

• Does the patient experience headaches on ≥ 15 days/month?
• Does the patient use triptans, ergots, combination analgesics, or opioid-containing medications on ≥10 days/month?
• Does the patient use acetaminophen or NSAIDs on ≥ 15 days/month?

If any of the above, then diagnose medication-overuse headache.

• Consider the medication that caused the problem in the first place before stopping the medication cold turkey:
  • Gradual withdrawal of opioids
  • Abrupt (or gradual) withdrawal of acetaminophen, NSAIDs, or triptans
• Treat remaining severe headache attacks

Written by Maria Veinberg. Reviewed by Dr. Prokubovskaya & Dr. Premji