Headache: two views on the right approach in general practice.

Abstract

Headache is an example of a common symptom (others could be dyspepsia, bloating, or cough) which is usually of minor significance and clears up spontaneously but, rarely, is a warning of a serious underlying disorder. GPs often have to tread a narrow path between missing serious disease and over-investigation, which can be harmful as well as wasteful. We present two views on the approach to headache in general practice. Yes, they should, and it is difficult to argue the opposite, although the well-rehearsed arguments against scanning patients with headaches apply equally to neurologists and GPs. ### The value and cost of magnetic resonance imaging (MRI) #### ‘MRI rarely helps the diagnosis’ This statement is correct in broad terms, however, apart from migraine and tension headaches (the commonest types of headache), most other potential diagnoses require imaging to exclude unusual causes. Neurologists may be more knowledgeable about rare forms of headaches, but all the rare forms require imaging. The first presentation of cluster headache requires imaging, autonomic cephalalgia requires imaging, and cough headache requires imaging ... #### ‘MRI is expensive’ The same applies to hospital appointments. Gatekeeping is a characteristic of general practice, and not a forte of neurologists. An interesting exercise would be to compare the proportion of patients referred for an MRI by their GP when they consult for headaches, with that of patients attending headache clinics. ### An integrated headache service In Nottingham city, access to MRI for patients with headache refractory to medical management is available in primary care. The service has been in place since 2010 and the number of patients referred via the GP MRI pathway has steadily increased from about 40 in the first quarter of 2010, to 130 in the first quarter of 2014. When we last looked at this cohort of patients, we indeed found some significant pathology that would immediately alter patient management.1 As expected, we also found a moderate percentage of truly incidental findings, …