Headache is a common problem. We've all had them—especially at 3 am after the fifth call and no meal break—and the figures back this up. In primary care, 4% of consultations relate to headache, being the most common neurological presenting condition in accident and emergency (A&E), with figures for attendance due to headache rising steadily year on year (Thames Valley Strategic Clinical Networks, 2017).
So it stands to reason that as ambulance clinicians, we will come across it regularly as a presenting condition. In one trust last month, there were 15 calls a day, every day, to 999 for ‘headache’. Not only is it common, it is also complex. First there are primary or secondary headaches, and these two groups then split further into other groups, some of which split even further. Add to this the fact that one of the most commonly presenting primary headaches is also a ‘stroke mimic’, and it all gets rather difficult.
In training, there was a phrase that visiting consultants liked to use: ‘Common things occur commonly’. It was used to reassure us that those rare and sinister cases were few and far between. With headache, though, this perfectly highlights how that reassurance represents a double-edged sword. While it is likely that a patient's headache is benign, there are rare causes to catch us out and we won't have seen them often if ever, so we may struggle to recognise them with a ‘clinical portrait’ or schemata. We are not alone as GPs diagnose migraine correctly in 98% of cases; but when making a non-migraine diagnosis, they are wrong 82% of the time.
Conversely, while we would never want to miss a serious pathology, we equally do not want to add to the burden of our A&E colleagues by delivering patients who have an eminently self-treatable condition. However, to direct the patient appropriately, be that consultation face-to-face or over the phone, we must be certain of our decisions.
In order to reach safe and appropriate decisions, we need to ensure we have up-to-date knowledge. So, can this month's book help us to achieve this?
Published by Cambridge University Press, Emergency Headache: Diagnosis and Management initially appears fairly lightweight at 160 pages, but it packs a wealth of information spread over 14 well organised chapters. The three editors are all doctors currently practising in the field of neurology and, more specifically, headache. One specialises in paediatric headache, one in ‘emergency room’ headache and the third is a professor and president of the International Headache Society.
Each chapter is authored by an expert, or experts, in the chapter subject. Note however that this is an American book, with American spelling and a lot of the statistical data are drawn from west of the Atlantic. As we will see, there is a strong focus on when and how to investigate, possibly driven by living with, and working in, an insuranceled health system. This is not an issue with regards to the clinical information, however, which would be the ultimate reason for owning the book for most.
This has to be considered a proper ‘textbook’, not for quick and ready referencing. While it does contain some tables referencing details such as red flags, these are each contained within the appropriate chapter, and it would certainly not be a book for quick aid with ‘on the spot’ clinical decision-making. This book serves to increase knowledge and act as a desktop reference. This said, it can be read a chapter at a time as each is independent of the other.
The preface and introduction give a good overview of the book and its aims, as well as a brief overview of the topic itself. It also starts to describe how headaches are labelled medically, pointing the reader to the International Classification of Headache Disorders as the definitive guide, and certainly one worth using alongside this book; although the book itself does contain plenty of relevant detail from it.
The next chapter provides us with the epidemiological facts of headache. As previously stated, few of these relate to the UK, but it paints a clear picture of the effect on healthcare provision.
Chapter 3 is a key chapter, giving pertinent information on history-taking and physical examination, while highlighting some clinical ‘pearls’. This is the information that is practical and helpful in the initial stages of managing the patient. It also provides some ‘high yield questions’, which help to focus the patients' answers so the clinician can quickly rule in or out certain conditions.
Chapter 4 is where it becomes really clear that this book has been primarily written for those working in the hospital emergency setting. It provides a thorough description of tests to be considered, how they work and the rationale for them. While this initially seemed of little use for paramedics on the frontline, as opposed to within A&E, it does make clear what might be reasonably expected as part of a management plan for any particular patient. Knowing this may contribute to the decision-making for that episode of care and on the patient's pathway in the prehospital setting. However, this is repeated in the following six chapters' content, where each concludes with varying amounts of further information on specific tests and investigations that should be undertaken at hospital.
Those next six chapters all relate to types of headache directly. The first two discuss secondary headaches and the remaining four, primary headaches. These chapters are broadly similar in that they offer descriptions of each headache subtype; although they tend not to go too deep into the pathophysiology, the symptomatic detail is great, as is the breadth of coverage.
It is doubtful that a paramedic would come across a headache that is not mentioned somewhere in this book. It gives tips on recognising and differentiating (paramedic gold dust!) and headache types that fall into the same category. The rest of each chapter then generally discusses investigation and treatment, which may not be of much value to some.
The first of these chapters covers ‘thunderclap’ headache. This chapter, while addressing one of the headache types that causes most concern in staff, provides some enlightening insight into the causes of this headache type. Alongside recognising the increased risk and alternative sinister causes, other than subarachnoid haemorrhage (SAH), it also covers a range of non-life threatening causes. The following chapter is dedicated to ‘other secondary’ headaches. It then moves on to migraine, which is very treatment-heavy, followed by trigeminal autonomic cephalgia (TAC) and then ‘other primary’ headaches, finishing on an interesting read about medication overuse headache (MOH).
The following three chapters deal with special patient groups. It kicks off with another key chapter, the paediatric headache. If staff worry about headaches in adults, it can be pretty much guaranteed that this is magnified in children. Reassuringly, only the second sentence in, the experts state how the majority of paediatric headaches are not life-threatening. It is generally agreed, in opposition to the adult population, that secondary headaches are the most common type in children, with the commonest underlying cause being a viral illness. Despite their reassurance though, the authors do not neglect their duty and continue to provide a full guide to history-taking and examination specific to the paediatric patient, which all would find useful.
It is followed by a chapter on pregnant and lactating patients which, after giving some interesting information on the natural history of headaches in pregnancy, concentrates mostly on the pharmacological treatment and its effects to the unborn or breastfeeding child. For anyone with an interest in pharmacology, it makes for good reading but is limited in its practical application in the paramedic sphere of practice.
The final patient group is the elderly; increasing age sees a corresponding rise in incidence of secondary headaches which, coupled with comorbidities, increases sinister presentations. We are treated to a specific history and exam model for the group, along with lists of drugs likely to cause headache—all useful stuff.
In the current climate, where there is an appetite for discharging on scene and treating patients at home in order to promote efficiencies, the final chapter of the book is very appropriate—and novel. It is focused on preventing ‘bounce-backs’ by ensuring the patient's episode of care and plan is right first time. It is certainly thought-provoking.
Without taking away from this book, as it does exactly what its title suggests, it is not one to buy as a quick guide or pocket reference. Further, the lack of a glossary in a book with so many abbreviations means that each chapter ideally needs to be read from the start.
That aside, this is a worthy book and, while frontline paramedics may not be the target audience, it is certainly informative on its subject. Whether people would want a book that also includes so much information on investigations and treatment is an entirely personal choice and there are, no doubt, other books about headache with less focus on these aspects, just as there will be ones with a stronger focus on pathophysiology. For an informative all-round read, it is a great choice.