Chronic daily headaches may go underreported

A significant percentage of patients in the primary care setting experience headaches more than 15 times a month -- a fact not always shared with physicians, says a study in the January Headache: The Journal of Head and Face Pain.

"Chronic daily headache may be more prevalent than primary care doctors realize," said Remy Coeytaux, MD, PhD, lead author and assistant professor of family medicine at the University of North Carolina School of Medicine, Chapel Hill. "And for a number of reasons, patients seem hesitant to report headache as a problem that warrants their physicians' attention."

Researchers sent surveys to 1,500 randomly selected patients who had come to an academic family medicine clinic in 2004. About 9% of the 853 who returned the questionnaire reported symptoms consistent with a diagnosis of chronic daily headache. This incidence rate is significantly higher than the 3% to 5% of the general population figures prior studies have documented. Of patients with chronic daily headache, 32% did not believe or were not sure that their physicians knew about their pain.

The authors are calling for educational efforts to make it more likely physicians will ask patients about headache pain. There also is hope that additional attention to this syndrome will lead to the identification of those at risk for developing it and increase the targeted use of preventive strategies, particularly since chronic daily headache frequently has its roots in less-frequent head pain, accompanied by overuse of medications to remedy it.

"We have an opportunity to improve the diagnosis and management of headache disorders," Dr. Coeytaux said.

Because this survey was carried out in a population at an academic center and the response rate was 57%, its application to other primary care settings is unclear. Experts did, however, praise the paper for adding to the increasing body of data documenting the frequency of chronic daily headaches.

"It calls to the fore a very important problem, and it raises a lot of interesting questions," said Gretchen Tietjen, MD, professor and chair of the Neurology Dept. at the University of Toledo in Ohio. She is also a spokeswoman for the American Academy of Neurology.

A communication challenge

Those who work with patients with these kinds of disorders say it's a challenge for physicians to know the extent of patients' headaches. For instance, in this study, 28% of those with this complaint said they didn't need a doctor's care. Patients may not be aware that physicians can do anything for them, and, particularly if the pain is not disabling, may not regard it as important enough to bring up.

"Patients unfortunately do a disservice to themselves if they feel it's not worthy of discussing, because we have effective forms of treatment," said Gerald Smetana, MD, associate professor of general internal medicine at Harvard Medical School and Beth Israel Deaconess Medical Center. "We need to be teaching patients that headache is a treatable condition."

Also, headache experts say patients are more likely to talk about their worst episodes while overlooking those that hurt less but last longer or occur more frequently.

It is for this reason that experts recommend asking about painkiller use rather than headache severity to illicit a more accurate picture of a patient's headaches.

"Ask: 'How many days do you treat a headache?' " said David Dodick, MD, professor of neurology at Mayo Clinic in Scottsdale, Ariz., and treasurer of the American Headache Society. "You find answers you never expected."

In addition, those who have them so frequently are unlikely to have this problem as their only one. In other words, headaches may not top their agenda. For example, another study in the same issue of this journal from researchers at Italy's University of Modena and Reggio Emilia found that chronic migraine patients were far more likely to have other psychiatric and gastrointestinal issues than were those who have these types of headaches less frequently.

Experts suspect that this may explain in part why the prevalence is higher in the primary care population even though many of these patients are not going to doctors for headache care. They may have other conditions associated with their headaches and the use of pain relievers that they may view as more important.

"It's uncommon for a patient to just talk about headache," said Morris Maizels, MD, a family physician and director of Kaiser Permanente's Woodland Hills Headache Clinic in California. "Typically patients bring four to five concerns per visit, and headache is not commonly the No. 1 concern."

But experts say it is important to overcome these blocks to confirm that there is not something more serious going on. It is also essential to make it less likely that patients will suffer adverse events from long-term use of over-the-counter pain relievers, such as a worsening of the headaches or kidney and liver problems.

"These drugs have consequences that can catch up with people," Dr. Dodick said.