2012年NICE青少年和成年患者头痛诊断和管理指南

Headaches are one of the most common neurological problems presented both to general practitioners and to neurologists. Local primary care trust reports indicate that headache accounts for 4% of primary care consultations and up to 30% of neurology out-patient appointments.

Headache disorders are classified as primary or secondary. The aetiology of primary headaches is poorly understood and they are classified according to their clinical pattern. The most common primary headache disorders are tension-type headache, migraine and cluster headache. Secondary headaches are attributed to underlying disorders and include, for example, headaches associated with medication overuse, giant cell arteritis, raised intracranial pressure and infection. Medication overuse headache most commonly occurs in those taking medication for a primary headache disorder. The major health and social burden of headaches is caused by the primary headache disorders and by medication overuse headache.

Headache disorders are a cause of pain and disability. They also have a substantial societal burden. Migraine, for example, occurs in 15% of the UK adult population, and more than 100,000 people are absent from work or school as a result of migraine every working day. Cluster headaches are less common affecting, perhaps, 1% of the population at some time in their life. Bouts of cluster headaches can be extremely disabling.

Although primary headaches can affect people of any age their main impact is in young adults many of whom have both work and family commitments that are affected by their headaches. The impact is not just during a headache but the uncertain anticipation of a headache can cause a significant burden between attacks. Globally migraine and tension type headache contribute similar proportions to the headache burden244. As well as impact on the person with headaches primary headaches can a have a substantial effect on the life of other family members244. Across Europe the cost of migraine alone may be as high as €27 billion per annum.

Many non-specialist healthcare professionals can find the diagnosis of headache difficult, and both people with headache and their healthcare professionals can be concerned about possible serious underlying causes. This leads to variability in care and may mean that people with headaches are not always offered the most appropriate treatments. People with headache alone are unlikely to have a serious underlying disease. Comparisons between people with headache referred to secondary care and those treated in primary care show that they do not differ in terms of headache impact or disability.

Many people with headache do not have an accurate diagnosis of headache type. GPs lack confidence in their ability to diagnose common headache disorders. They can feel under pressure to refer people for specialist opinion and investigation. Most common headache types can be diagnosed on clinical history and can be managed in primary care. If specialist advice is needed on headache diagnosis and management this can be provided by a neurologist with an interest in headache or a GP with a special interest (GPwSI) in headaches, or for young people under 18 years of age; a general hospital or community based paediatrician or paediatric neurologist. Within this guideline the term specialist is used to mean either a neurologist, GPwSI, paediatric neurologist or paediatrician with a special interest in headache.

This guideline does not cover secondary headaches that require more specialist management, for example headaches that are due to an underlying infection (e.g. meningitis) and cervicogenic headache. Facial pain and occipital neuralgia are also beyond the remit of this guideline.

Improved recognition of primary headaches would help the generalist clinician to manage headaches more effectively, allow better targeting of treatment and potentially improve quality of life and reduce unnecessary investigations. Improved diagnosis of primary headaches and better use of available treatments has the potential to substantially reduce the population burden of headache without needing substantial additional resources.