Recent NICE guidance aims to assist health professionals to recognise and treat headache disorders effectively
In this article…
- The purpose of a headache diary to aid diagnosis
- How nursing input impacts on management
- The problems of medication overuse
Ria Bhola is headache nurse specialist at The National Hospital for Neurology and Neurosurgery, London
An exclusive summary of new NICE guidance from a member of the guideline development group.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file at the top of the page
In September 2012, the National Institute for Health and Clinical Excellence published its clinical guideline onthe diagnosis and management of headaches. The guideline will enable patients (aged 12 and above) who suffer with primary headache syndromes to obtain the best evidence-based care and management.
Headaches are one of the most common neurological problems presented to GPs and neurologists in the UK.
They are painful and disabling for individuals who often have to miss school, work and family activities as a result. This represents significant individual suffering and, consequently, high economic costs.
Headache disorders may be primary or secondary. The most common primary headache types are tension-type headache, migraine and cluster headache. Secondary headaches are those caused by other underlying disorders, such as infection, raised intracranial pressure and medication overuse. Medication overuse is the only type of secondary headache that is covered in the NICE guideline. It has been estimated that 1-2% of the population experience headache caused by this.
In practice, obtaining the right diagnosis is a crucial first step because it influences treatment choices. To assist with this, patients are encouraged to keep a headache diary for a period of at least eight weeks. The purpose of this is:
- To record the frequency, severity and duration of symptoms;
- To monitor the effectiveness of headache interventions;
- To act as basis for discussion with the patient about their headache disorder.
In practice, many people who experience headache have to wait for years for an accurate diagnosis and appropriate treatment. Crucially, the recognition and diagnosis of primary headaches and the ability to distinguish these from secondary causes can save time, suffering and resources.
Once any underlying pathology has been ruled out and the diagnosis of a primary headache is made, nursing input can have a significant impact on management. This includes:
- Offering an explanation of the disorder, reassurance and links to support organisations;
- Explaining options, which may include both acute and preventive medication treatments, taking into account the person’s preference and any relevant co-morbidities.
People who are using acute treatments should be advised of the risk of medication overuse. Once a treatment plan has been agreed and initiated, interim patient reviews and supervision of treatment become crucial.
The NICE guideline highlights the frequently unrecognised problem of medication overuse. Many patients take frequent pain-relieving medications. If these are taken too often, they can increase the frequency of headaches. The overused medication should be stopped for at least a month, after which acute treatments may then be reintroduced at a reduced frequency.
Patients will often refer back to the nurse for support, advice and management of this process, which can bedifficult with an initial worsening of headache and the emergence of withdrawal symptoms. However, reassuringly these symptoms settle and good outcomes generally follow.
Treatment monitoring and review
Patients with headache will require appropriate reviews to assess the efficacy of treatments, tolerance to medications, support and advice to achieve the optimal medication dosing - all of which will contribute to achieving successful outcomes. The headache diary should also be maintained to assist with this review.
The NICE clinical guideline gives specific treatment options for each of the main primary headache disorders, with advice on when to refer to secondary or specialist services for diagnosis and management. This guideline should improve the recognition and treatment of headaches, and enable patients to obtain appropriate treatment.
National Institute for Health and Clinical Excellence (2012) Headaches: Diagnosis and Management of Headaches in Young People and Adults