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CG150 Headaches podcast

Professor Martin Underwood discusses the guideline's recommendations on diagnosis of headaches and the impact it has on general practice.

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This podcast was added on 19 Sep 2012

Podcast transcript

CG150: Headaches

Professor Martin Underwood, Chair of the Guideline Development Group, discusses the clinical guideline on the diagnosis and management of headaches.

Hello and welcome to this podcast from NICE. This month sees the launch of a new clinical guideline on the diagnosis and management of headaches.

Joining me to discuss the guidance is Professor Martin Underwood who is the Chair of the Guideline Development Group responsible for putting this guidance together. Martin is also Professor of Primary Care Research at Warwick Medical School.  

Q1: “So headaches are often thought of as a fairly trivial and common complaint so why do we need national guidelines on this topic?”

MU: “Well, whilst you’re correct that headaches are very common they’re not always trivial. Of course we all get everyday headaches. We all get the ordinary tension type headache for which all you need to do is to take simple painkillers, things like paracetamol, ibuprofen, aspirin, these types of things.

“But there are larger numbers of people who get a lot of severe problems with headaches that can be really quite disabling and are often very badly diagnosed. And with this guidance I think we can get much better diagnosis of headaches and be able to therefore target the most effective treatments at people who are getting the most problems from headaches.”

Q2: “So why are headaches currently poorly diagnosed? What are the problems that are occurring?”

MU: “I think that it has been a very confusing area for diagnosis and as patients or GPs if you look at all the different types of headaches people can get it can be very difficult to work through these.

“But one of the things we’ve done for this guideline is to produce some fairly simple straightforward sets of diagnostic criteria to allow people to sort out the common everyday headaches that cause the vast majority of headache disability.

“By doing that it means that we can give people the right diagnosis and that leads inevitably into better treatment and focusing on this.”

Q3: “Now, there’s a recommendation in the diagnosis section that looks at diagnosing medication overuse headaches. What do we mean by this?”

MU: “Well, medication overuse headaches, this is a group of people who for whatever reason they’re getting headaches they take painkillers for them and they end up taking painkillers more and more because they’re getting more and more headaches. And if you’re taking these for more than 10 or 15 days a month, depending on which type of painkiller it is over a period of months, then these in fact end up causing headaches. You end up getting into a really vicious circle where you get headaches so you take painkillers which give you more headaches so you take more painkillers.

“And this is really important for two reasons. One is that it is preventable because if only people knew about this and knew not to take too many painkillers, particularly some of these painkillers that are not particularly effective for headaches like codeine, for example, hasn’t been shown to be effective, then we can prevent it.

“But also giving people yet more drugs to get rid of these headaches it just won’t work. People need that clear advice of you’ve just got to stop your painkillers, stop them now, stop them completely. Only by doing this will they get rid of their headaches.

“It’s difficult advice to give to patients. It’s not something that they welcome. And of course you have to tell them that it’s going to be two, three, four, five weeks over which their headaches are going to get worse before it all gets out of their system and starts improving.

“So it does take a lot of courage and strong will from patients to go through and do this but if they can get through that this can very often successfully dramatically reduce their headaches.”

Q4: “And are there any particular recommendations for diagnosing migraines in this guideline?”

MU: “Yes, there is clear guidance for the diagnosis of migraine clearly distinguishing it from the less severe more episodic tension type headache.

“Migraine, the sort of headache that is throbbing, moderately severe headache, stops you getting on with everyday life and there is clear guidance for that.

“Also clear guidance about when to diagnose a migraine or distinguishing them very clearly from the medication overuse headache and also the much more severe pains that you get with cluster headaches.”

Q5: “Now, 97 per cent of headaches are managed in primary care so what are the main management recommendations for GPs?”

MU: “This boils down into good acute treatment for the headaches when the headaches are there. If you don’t mind I’ll have to break these down into the different types of headaches.

“So for tension type headaches simple painkillers, things like paracetamol, ibuprofen, aspirin, are just fine. For migraine, then here we should be looking at combination treatment. Now, this is something new and different in the guidance and it’s important to change how we do things.

“Traditionally we advised just a single painkiller but we’re now saying actually what you should do as first line treatment you should use combinations of painkillers.

“You should take a triptan, something like sumatriptan and an anti-inflammatory drug, something like ibuprofen or naproxen. Take both of those together as your first choice of treatment as being the most effective.

“If people don’t want to do that they can try just one but we think that the evidence clearly shows that double therapy is better. In addition, some people will find that anti-sickness pills, drugs like metoclopramide, these types of drugs, will be helpful even if they are not feeling sick. So sometimes people would need to take all three of these tablets together and that can be a very effective treatment.

“Cluster type headaches, again very clear new guidance here as to what we should do with this. First of all we should be offering everybody oxygen treatment. They need to be provided with a good supply of oxygen. They need a 100 per cent oxygen at 15 litres per minute available to use as soon as their headache starts. And this can be ordered by GPs through the HOOF (home oxygen order form), through their usual supplier, to get that into the home as soon as possible.

“This isn’t always practical when people are out and about so you should also supply them with a triptan. Not an oral triptan. Triptan tablets, they just don’t work for this it needs to be an injection or intranasal. That can be very effective. Also people with cluster headaches, oxygen can be so effective you need to think about other ways of delivering it. So as well as at home they will need ambulatory supply to take with them. Some people may need a supply at the office. But this stuff is so effective this is well worth going to the trouble.

“That’s all about the treatment of when it’s there. In terms of prevention to stopping the attacks coming on, clearly you need to discuss this with the patients and balance up the risks and benefits of the different treatment choices.

“But then for tension type headache there is good evidence that a course of acupuncture treatment can be helpful for this so this would be worthwhile considering for those people who are having a lot of trouble.

“For migraine there are more choices. There are two drugs that we’re recommending. The first is topiramate the second is propranolol. Crucially there’s quite a range of drugs that are widely used, things like pizotifen and amitriptyline, that we’re not recommending but the best evidence is for topiramate and propranolol.

“Most GPs will be familiar with using propranolol and they’ll often prescribe this. They will be less familiar with using topiramate and so there will be a little bit of learning for them here to get familiar with the drug, particularly because of its risk of causing foetal abnormalities in pregnant women. Which can be particularly problematic because not all methods of contraception can be effective with topiramate so they will need to look up specialist advice on how to give contraceptive advice to women of childbearing potential who are taking topiramate for their migraine. But it is a very effective drug and this is something well worth doing.

“If those don’t work there are some other alternatives that people can think about. In terms of drugs there is some evidence that supports the use of gabapentin. And, again, there is evidence to support the use of acupuncture. A course of acupuncture treatment could be very effective in preventing the recurrence of migraine.

“And finally coming back to the cluster type headaches, then the drug verapamil can be used. This may need quite high doses and in general most GPs are going to need to take specialist advice for using this. But, again, it can be a drug that can be very effective at reducing the recurrence during a bout of cluster headache.”

Q6: “And in terms of improving the management of headaches do you think that effective management can help the NHS save money?”

MU: “Well, of course these guidelines are not about saving money they’re about improving patient care. But there are some of the recommendations in here that do have the potential to save some money. Because all of the drugs and medications and treatments we’re offering are things that are widely available anyway.

“But we are, for example, advising against the use of imaging techniques for reassurance in people with these common headache types so there should be a reduction in the use of scans in people with simple headaches. And also we would hope that by improving quality of diagnosis in general practice there will end up being fewer referrals into secondary care which again would have the potential for reducing costs in the NHS.”

Q7: “And finally, do you think that the presence of NICE guidelines for headache care will help to raise the profile of the area within general practice?”

MU: “I sincerely hope so. Headaches have been an area that’s been quite neglected. There’s often a perception out there that headaches are not a valid medical disorder because of course you can’t see a headache. A patient can only tell you that they’ve got the headache.

“Pushing this up the priority list for GPs I think is important because with the right diagnosis and the use of the effective treatments that we’ve identified then there are things that we can do that are useful and GPs will perhaps feel a bit more positive and empowered about how they can deal with this.

“And to put the importance of this into perspective and how important it is that we do manage these better, apparently migraine is reckoned by the WHO to have the disorder with the tenth highest disease burden in the world. So it is a really important problem that needs tackling better.”

Martin, thank you very much for your time.

19 September 2012

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This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.

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This page was last updated: 19 September 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.