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Managing migraine and headache in primary care

In the first of two articles on how to manage headache and migraine in primary care, Manuela Fontebasso looks at how to diagnose and recognise red flag symptoms, and how to best support the patient with initial nondrug interventions

Manuela Fontebasso
GP and GP with Special Interest in Headache
Department of Neurosciences
York District Hospital

Headache is a common presenting symptom in primary care and may reflect a primary headache disorder, migraine, tension headache or cluster headache, or represent a secondary headache disorder such as medication overuse headache, meningitis, diabetes or more rarely a brain tumour.
The aim of this article is to supply you with a framework that can be used in the clinical setting:

  • To diagnose the common primary headaches. 
  • To recognise red flags in order to be able to refer patients to the most appropriate individual to diagnose and treat their headache.
  • To offer advice on nondrug interventions to reduce the number of headache days.

Differential diagnosis of headache
Diagnosing headache, in my experience, is about pattern recognition. If you ask the right questions then you will gather the information to identify the headache. The International Headache Society (IHS) has developed the diagnostic framework for headache disorders, which was revised in 2004.1 Table 1 shows the diagnostic features of a variety of primary headache disorders presented in a way to aid differentiation between them. Chronic headache, often presenting as daily headache, is a common problem, with medication overuse headache affecting one in 50 adults.(2,3) The criteria for chronic headache were revised in 2006 (see Table 1).(4)


Taking the history to make the diagnosis
Patients will often ask for advice about their headache at the end of a consultation about a completely unrelated condition. Headache diagnosis is made on the basis of the history.(2) Taking a headache history is not something that can be done in a few minutes, but it is possible to show interest in the patient's situation, offer them an assessment card to complete and invite them back for a fuller assessment, explaining that the reason for doing this is that it will give them time to carefully think about their symptoms and assist you in making the correct diagnosis in order to offer them the most appropriate advice.
At the Headache Clinic in York I have developed a standard history sheet that aids me in my history taking, speeds up data entry and ensures that I remember to ask all the relevant questions (see Box 1). It also allows clarity of record keeping. In taking the history I explain that I will ask a lot of questions, which sometimes can be difficult to answer, but I need to understand their symptoms in order to be able to make a diagnosis. The detail is always important and words and phrases can mean different things to different people, so as the person taking the history you need to be confident that you know what the patient is describing rather than assume you know what the patient means by what they are describing.
Box 1 shows a framework of questions that will assist you in your history taking and could be used to set up your own computer-based protocol in your practice.


Secondary headache - awareness of red flag symptoms
The majority of patients who present with headache will have a benign primary headache. Despite this it is important to have an awareness of the symptoms that may indicate a secondary headache that needs urgent intervention and investigation.(2) Many of these will be self-evident, but sometimes what may seem to be a red flag symptom actually reflects part of the primary headache history and needs to be taken in the context of new symptoms, slightly atypical symptoms, or reflect an evolution of symptoms indicative of a more sinister pathology.
Box 2 outlines the sort of questions you need to consider when trying to exclude secondary headaches.


Nondrug interventions - addressing diet and lifestyle issues
Headache affects some people some of the time and some people a lot of the time. Reducing the number of headache days is not always about taking medication to relieve the headache, but may be about taking steps that will raise the headache threshold and reduce or prevent the headache developing at all.
Patients often talk about migraine triggers but I prefer to encourage them to think about their headache threshold - the lower their threshold the more likely they are to experience headache. The more they understand about how "triggers" affect them and how this effect can vary according to where their threshold is will encourage them to take more control over those aspects that can be modified. Every patient you see will have different needs and expectations; promoting self-awareness will allow them to manage their headaches more effectively.(2)
For example, if the patient always gets their migraine at the weekend is it always when they have a lie in or only when they have had a very busy week. Or is it when both happen in the same week? If they avoid the lie in they might be less likely to get the migraine or vice versa. If they manage the busy week and destress more they might be able to get away with the lie in, or if they have a bedtime snack to avoid the morning hunger. Triggers rarely work in isolation - think about how they come together and control the things you can control so that those you are less able to control are less likely to be relevant.
Box 3 outlines the sort of advice that can be discussed with patients when they present with any headache symptoms. This sort of advice can have a positive effect on all types of headache, not just migraine.


Patients need to understand their headache diagnosis and feel supported in the changes they need to make to feel in control of their symptoms. Diet and lifestyle advice can help most headaches most of the time. Listening to the patient will facilitate diagnosis, and giving patients time will encourage them to return for further review.
Once the patient is engaged in the process, there will be an opportunity to optimise their acute treatment, if needed, review the number of headache days and discuss the need for preventive medication. Every patient you see has individual needs and expectations, and offering a flexible approach to management will facilitate a more positive outcome, leaving the patient feeling more in control of their headache


  1. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia 2004;24 Suppl 1:9-160.
  2. Steiner TJ, MacGregor EA, Davies PTG. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache. Available from:
  3. Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol 2004;3:475-83.
  4. Headache Classification Subcommittee of the International Headache Society. New appendix criteria open for a broader concept of chronic migraine. Cephalalgia 2006;26:742-6.