New NICE guidelines on headaches
Hot on the heels of migraine awareness week the National Institute for Health and Clinical Excellence (NICE) has published new guidance on headaches.
Let's be entirely honest, as a GP my first instinct when a patient comes in to tell me about their headaches is 'meningitis or a brain tumour'. Logically, of course, I know that 'common things occur commonly' in general practice, and believe me, headaches with no other underlying cause (called 'primary headaches') are common - the statistic that headaches account for one in 20 GP consultations doesn't surprise me for a moment. These days, medical students spend much more of their training based in general practice - where half of them will spend the rest of their careers. But when I was a girl, you'd spent years in hospital, where the only patients you ever saw with headaches were the ones with life-threatening complications, before you ever got a whiff of life in the community. Small wonder that every medical student I knew was convinced they had a brain tumour at least once a year.
Does that mean I take my eye off the ball once I've ruled out an underlying cause, liked raised pressure inside the brain, to account for my patient's headaches? I sincerely hope not. But maybe, a bit like so many of my patients, experience tells me that a tension headache will usually settle with a couple of painkillers from the chemist. Unfortunately, all too many of us go through periods of getting headaches for days or even weeks in a row - after all, we all lead stressful lives, and tension headaches are called 'tension' headaches for a reason. Taking painkillers too often means the body gets used to them, and you get a withdrawal or 'rebound' headache within a day or so of the last dose. The natural reaction? Take more painkillers because you've got another headache. Before you know it, you've joined a not-so-select club - it's estimated that about one in 50 people suffer from these highly disabling 'medication-overuse headaches' and that women are five times more likely to get them than men (ref NICE guideline). Combination painkillers and migraine medications like triptans are particularly common culprits, and the new NICE guidance urges doctors to consider the diagnosis in anyone taking these medicines on 10 or more days a month. But even bathroom cabinet standards like paracetamol, aspirin and NSAIDs (non-steroidal anti-inflammatory drugs such as ibuprofen) can result in medication overuse headaches if they're taken on at least half the days in a month.
On the plus side, the authors hope that following the NICE guidance may mean fewer people being referred unnecessarily for brain scans and more patients getting the right diagnosis and the right treatment. On the down side, there is no quick fix for medication-overuse headaches. You need to stop taking painkillers completely, at least for a while, and there's no way to avoid the worsening of headaches in the short term. But within a few weeks, things really will get better if you persevere. And if the alternative is a lifetime of debilitating daily headaches, there really is no other choice.