Headache is the most common symptom reported in general practice; the lifetime prevalence is over 90%.1 Furthermore, 4.4% of patients see a primary care clinician about a headache every year, of whom 4% are referred to secondary care.2 Many causes of headache are self-limiting and can be managed with over-the-counter care, but some can be excruciatingly painful (the pain of cluster headaches has been compared to other very severe pains, such as childbirth), or associated with significant morbidity and mortality.
The new RCGP eLearning course on migraine and cluster headaches aims to improve knowledge in these areas, using a case-based approach to answer some of the following common clinical questions.
What is cluster headache and how can I be sure not to miss this diagnosis?
Cluster headache is part of the group of trigeminal autonomic cephalgias, which all have associated autonomic symptoms and are extremely painful. A patient with cluster headache will be very distressed. The headache will be unilateral, with ipsilateral symptoms such as a watering eye or nose, pupil constriction, sweating, and eyelid swelling. The patient may be agitated and unable to sit still, and they may have had a similar headache in the past, usually lasting up to 3 hours.3
Can I diagnose and treat cluster headache, or does it need a specialist?
A GP should be able to recognise and treat cluster headache, but should then refer to neurology (ideally on an urgent pathway) for confirmation of the diagnosis, exclusion of differentials, and consideration of prophylactic treatment such as verapamil, topiramate, and non-invasive vagus nerve stimulation.3,4 Initial treatment can be given in primary care and includes nasal or subcutaneous triptans (oral intake does not give a quick enough effect), or high-flow oxygen — the latter can be difficult to access acutely in primary care.3 Patients might benefit from a support group such as OUCH (Organisation for the Understanding of Cluster Headache), as well as occupational health support to deal with the effects on their working life. Some may become depressed or suicidal and need mental health support.
What is a migraine aura?
Aura is a focal neurological symptom that occurs before the headache or migraine, or at the start of the headache. About 25% of those with migraine get an aura, and for an individual person it is usually similar with every episode of migraine. It is caused by neuronal hyperactivity, followed by inhibition, and can cause positive or negative symptoms. These might include flashing lights, pins and needles, tinnitus, a blind-spot, or an area of numbness or motor weakness.
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Migraine aura sounds very much like a TIA or other vascular event — how can I tell the difference?
The short answer is that this might not always be possible in primary care. Auras that present with serious symptoms such as hemiplegia or aphasia, or auras without a headache, can only be clinically confirmed as being migrainous after more serious conditions have been excluded, and this will require secondary care assessment. Subsequent presentations of the same aura may be more confidently managed in primary care, but that will have to be decided at the time on a case-by-case basis.
Features in the history that might help to differentiate are as follows:
aura tends to be gradual onset, whereas vascular events happen suddenly;
symptoms of a transient ischaemic attack (TIA) usually come on and stay the same, before resolving — aura symptoms may vary;
TIA symptoms are usually (but not always) negative, for example, weakness, whereas aura more commonly has positive symptoms such as paraesthesia; and
patients having a TIA are likely to be older, with vascular risk factors, compared with the cohort who get migraine.
What should I do if I suspect a TIA, and cannot reassure myself that this is a migraine with aura?
Suspected TIA needs a same-day referral to the TIA clinic, to be seen within 24 hours.5 Three hundred milligrams of aspirin should be given (unless contraindicated, or the patient is already on low-dose aspirin). The previously used ABCD2 triage system is no longer recommended as it is not sensitive enough to differentiate between those at high or low risk. If someone comes in with a resolved TIA that occurred more than 7 days ago, they should be referred to be seen within 7 days. The urgency is because TIA is a warning sign for future stroke: 1.5% of those who have a TIA will have a stroke in the next 2 days, rising to 5% over the next year, and 17% over the next 5 years.
I am confident that my patient has a migraine — what might I prescribe?
Acute migraines are usually treated by triptans, which should be given during the headache phase rather than while the aura is present. High-dose aspirin with a prokinetic can also be used. Preventive options include propranolol, topiramate, and amitriptyline.6 A new class of drug, the CGRP receptor antagonists or ‘gepants’, has been approved by the National Institute for Health and Care Excellence (NICE)7–9 for those in which at least two triptans have not worked, or if triptans are contraindicated or not tolerated, and in patients with 4–15 migraines per month who have not benefited from at least three prophylactic agents. CGRP receptor antagonists are likely to be started in secondary care for the foreseeable future and can be given orally or by nasal spray.
It should be remembered that migraine with aura at any age is an absolute contraindication to use of any combined hormonal contraception (CHC).10 The development of migraine without aura, in a patient who is using CHC at the time when the migraine develops, is a strong relative contraindication in which the risks are likely to outweigh the benefits. The same applies to the use of CHC in a patient with a history of migraine with aura that has not occurred for at least 5 years. If migraine without aura predates CHC use then the contraindication is weaker, and the benefits are likely to outweigh the risks. Hormone replacement therapy can be safely used in those with migraine, including with aura; transdermal preparations are often recommended, for a more stable hormone level than tablets.
Notes
Provenance
Freely submitted; externally peer reviewed by RCGP Learning.
Competing interests
Toni Hazell has been a freelance medical writer and editor for, among others, Cogora, MIMS Guidelines, iheed, BMJ Learning, Assura, PCM Scientific, EMIS, Doctors.net.uk, and Blue Stream. She has had paid presenter and chair roles at conferences and webinars including for Livi, the RCGP, Primary Care Women’s Health Forum (PCWHF), Pulse, Nursing in Practice, Medscape, BMJ Best Practice, and MIMS. She has carried out freelance work for the RCGP accreditation department. She is a GP appraiser. She has received pharmaceutical/medical technology funding from Bayer, MSD, Viatris, Hologic, ALK Abelló, and Thermo Fisher. She has carried out consultancy work for MGP and Initiate. She is a board member of the PCWHF and is on the medical advisory board for the website Babycentre. She has done unpaid work for the British Association for Neurodiversity. A register of interests is available at: https://www.whopaysthisdoctor.org/doctor/515/active.
- © British Journal of General Practice 2024
References
- 1.↵
(2022) National Institute for Health and Care Excellence. Clinical Knowledge Summaries Headache — assessment,
- 2.↵
- 3.↵
(2022) National Institute for Health and Care Excellence. Clinical Knowledge Summaries Headache — cluster,
- 4.↵
(2019) National Institute for Health and Care Excellence. gammaCore for cluster headache. MTG46,
- 5.↵
(2023) National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Stroke and TIA,
- 6.↵
(2022) National Institute for Health and Care Excellence. Clinical Knowledge Summaries. Migraine,
- 7.↵
(2020) National Institute for Health and Care Excellence. Galcanezumab for preventing migraine TA659,
- 8.
(2021) National Institute for Health and Care Excellence. Erenumab for preventing migraine TA682,
- 9.↵
(2022) National Institute for Health and Care Excellence. Fremanezumab for preventing migraine TA764,
- 10.↵
(2019) Faculty of Sexual and Reproductive Healthcare. UK Medical Eligibility Criteria, .
