Everyday is a school day!
NICE (the National Institute for Healthcare and Clinical Excellence) have recently issued their new recommendation on the management of headaches in young people and adults.
For those colleagues not working in the UK and not familiar with the funky term, NICE was set up over a decade ago to reduce variation in the quality of treatments and aims to help resolve uncertainty about which medicines, treatments, procedures and devices represent the best quality care for the National Health System (NHS). Sounds nice, doesn’t it?! They have put a lot of guidance out there some of which we have already covered on St.Emlyns (Sickle cell & VTE guidance for example), so I like to keep a look out on what they are up to, and this particular recommendation caught my eye for several reasons.
First the title itself was somewhat unusual as NICE usually separates their recommendations into paediatric and “grown-ups”… I thought: “Really? A guideline, that applies to both children and adults? Less reading to do and worth a read then!”
Secondly, I remember as a junior trainee how much I dreaded seeing patients with a mysterious presentation of headaches, sometimes pitching up with symptoms for weeks accompanied by non-specific symptoms like dizziness, blurred vision etc. Diagnostic uncertainty from my end and zero patient satisfaction from the other were common occurences. This is a problem though as headaches are clearly debilitating for the individual, constitute a major health and social burdens they are a common reason for absenteeism from work and school (Ed – and of course let’s not forget that some of them are life-threatening). So, as a clinician you will come across it regardless of where you practice emergency medicine in the world.
As usual, NICE based their recommendation on systematic reviews and where none were available on what I like to call the “grey-haired clinician’s subjective opinion” (or authority-based medicine if you prefer). No ageism intended!
So what of the recommendations themselves? Some of the initial recommendations are “common sense” (though I believe in evidence-based practice rather than common sense medicine) and did not surprise me at all. It is what we teach the juniors to do everyday: investigate or refer headaches with fever or new neurological symptoms, those of a sudden onset or those accompanied by a loss of consciousness.
Some however, left me baffled! NICE suggest referring or further investigating headaches that get worse with Valsalva maneuver or with exercise. I do not know about you folks but when I get home after a hard day at work with a banging headache, it tends to get worse with a sneeze or if I get on the spinning bike! I therefore considered this clinical information to be a poor predictor of bad outcome and a poor diagnostic feature.
Let us not forget that most of our final diagnosis is actually based on clinical examination and interpretation of presenting features. A small table about features helping the diagnosis of primary headaches looked very much like a reminder from medical school but was very handy indeed.
I however always found that patients in Virchester look at me blankly and really struggle to describe their symptoms when I ask them the unavoidable question: “Would you be kind enough, Mrs X, to describe the nature of your headache?”. I often imagine myself in the patients’ shoes and think they find this question rather comical (well, they would if they were not in tears after a week of agonising pain) and futile (“Does it matter doc? Just sort it out now!”). Anyway, good table for the juniors and those preparing for exams.
“Be aware of medication overuse headaches” they go on to state. The British media covered this question for a couple of days not that long ago and there is no doubt that in a society of consumers where painkillers are available over the counter, we do abuse them easily and maybe stricter regulations are needed in the near future.
In the management section NICE recommend not performing imaging in patients where the clinicians have diagnosed a primary headache solely for reassurance. Reassurance of the clinician or that of the patient? Both equally important I would argue. Good communication skills are needed here to tackle patients’ disappointment when you will let them know they will not get a scan as recommended by their neighbour!
Parts of the proposed clinical management are discussion with the patient and re-assurance. Again, not a skill we were traditionally taught at medical school…
Acupuncture for tension-type headaches based on a single randomised trial? “You are having a laugh, doc?” reflects my personal opinion too but I guess it is a low risk intervention, worth a try. I do not know about the overall costs.
Same for Riboflavin or vitamin B2 in migraines, with or without aura. I guess the clinician could throw in the “five a day” here to convince the skeptical patient (and colleague): it will probably not harm.
We knew about the benefit of oxygen administration in cluster headaches and I have been using it in my clinical practice for years (with moderate results). Arrange ambulatory and home oxygen say NICE. I would struggle to arrange that in Virchester from my local ED I have to confess.
Overuse headaches are caused by… abuse of analgesics. Surprised? I was however genuinely surprised that NICE recommends stopping medications abruptly and not progressively! Only half of those who succeed in stopping will be given such a definite diagnosis. A new approach for addictive illness?
In summary, this guideline did not add anything new to my clinical practice but did come up with some interesting suggestions. It is a good aide-mémoire for the trainees and a trigger for future research.
The authors particularly suggested the followings as areas of future research:
- Can a course of steroid treatment help people with medication overuse headaches withdraw from medication?
- Can psychological interventions improve headache outcomes and quality of life?
Ok, it is almost tea time in the UK. I still drink mine with lemon. I think I am addicted to either the theophylline or the lemon. I hope it will not give me a headache…
Janos P Baombe