Approach to a patient with a headache in the general practice setting

Uvod. Glavobolje se definišu kao bol lokalizovan iznad orbitomeatalne linije. Dijagnostikuju se i leče nedovoljno. Cilj rada. Ispitati koliko lekari u opštoj medicini znaju o dijagnostičkom i terapijskom pristupu glavoboljama i da li postoji razlika u odnosu na pol i region gde rade. Metod. Na našem godišnjem skupu, Dani opšte medicine, održanom 30.03.2019. godine u Beogradu, realizovana je akreditovana provera znanja na temu Pristup pacijentu sa glavoboljom u opštoj medicini. Test koji je sadržao 50 pitanja o rešavanju kliničkih problema kod različitih tipova glavobolja, položen je sa >60% tačnih odgovora. Podaci su obrađeni softverskim statističkim paketom SPSS 20. Statistička značajnost je definisana za nivo p<0,05. Rezultati. Test je popunilo 432 lekara, sa 98,4% tačnih odgovora. Primenom stratifikovane terapije, migrenu leči 29,5% (p=0,746). Antiemetike ordinira 7,2% lekara. Indometacin kao dijagnostičko-terapijski test poznaje 38,4%. Kortikosteroidnu terapiju kod arteritisa džinovskih ćelija pravilno primenjuje 57,7%. Glavobolje uzrokovane vaskularnim poremećajima imaju 56,9% tačnih odgovora. Njih 31,7% ispravno sumnja na disekciju unutrašnje karotidne arterije (p=0,631). Intrakranijalnu neoplazmu 40% lekara dijagnostikuje magnetnom rezonancijom. Ispravan pristup kod hipertenzivne krize ima 87,2%. Bakterijski meningitis uspešno prepoznaje 83,3% ispitanika. Dijagnostiku i terapiju glavobolja koje se pripisuju supstancijama ili njihovoj obustavi, prepoznaje 74,2%, a prekomernoj upotrebi medikamenata 51,9%. U odgovorima nema značajne razlike u odnosu na pol, ali su lekari iz uže Srbije dali više tačnih odgovora (p=0,005). Zaključak. Lekari su pokazali visok nivo znanja o dijagnostičkom i terapijskom pristupu glavoboljama. Nedostaju znanja o glavoboljama uzrokovanim kranijalnim ili cervikalnim vaskularnim događajima. Ključne reči: Glavobolja, dijagnostika, terapija, primarna zdravstvena zaštita.


Introduction
Headaches are defined as the pain localized above the orbital-meatal line. 1 It`s often a disease in itself, but very often it`s a symptom of some other disease. They may be primary or secondary headaches. 2 Half to three-quarters of the adults (18-65 years) worldwide experienced a headache in the previous year. Among them, 30% reported they had a migraine. A headache lasting 15 or more days a month, every month, (chronic headache) is found in 1.7 -4% of the world adult population. Almost every human being experienced it once in a lifetime. 1 Headaches prevalence is 66%. Migraine is found in 14%-16%, tension headaches in 46%-78%, cluster headaches 0.1%-0.3%. 3 A large number of people with headaches are never diagnosed or treated. Only 40% of migraine cases are diagnosed worldwide, and half of the people with headaches are self-medicating 1 . Headaches are underrated, insufficiently recognized, and inadequately treated all over the world. Despite regional variations, headachea are a worldwide problem no matter the age, race, geographic and economic area. They are a burden to public health, due to disability and economic consequences to society, since they usually affect the working population.
A headache is the most common reason for visiting GP, whether as a main complaint, or a side one. Migraine and tension headaches are the most common sorts of headaches all over the world. They are a global problem because they affect people of all ages, races, social statuses, and geographic places (less so in the Far East). 2 Unawareness of the importance of headaches leads to circulus vitiosus: insufficient GP`s education leads to insufficient knowledge and inefficient treatment, which leads to an increase in the number of days in the sick leave and implies financial consequences to the health system. Clearly, better education would lead to better prevention and treatment, and therefore better outcomes for an individual and the society as a whole. So, it`s no wonder just a few countries have got data, on the national level, on the headache incidence (disease registers). Only 12% of all countries offer data on headache incidence in their annual reports. 2 Headaches are often not taken seriously because the attacks are usually temporary, not life-threatening to the patient and his surrounding. Patients, and even physicians, think of the headache as harmless and fleeting. Personal suffering, worse life quality of the patients and their families, huge financial expenses for the treatment, and lower salaries due to the sick leaves, are often overlooked. Besides suffering in repeated headache attacks, patients are in the state of constant fear of the new attacks; this predisposes them to other disorders; anxiety and depression are more common among persons with migraine than healthy individuals. 1 Pristup pacijentu sa glavoboljom u opštoj medicini Оpšta medicina 2020;26 (3)(4):43-58

Objective
We wanted to find out how much general physicians (GPs) know about the diagnostic and treatment approach to headaches, and whether there was a difference in relation to their gender and region of Serbia where they worked.

Method
At our annual meeting, General medicine days, held in Belgrade, March 30 th , 2019, we accredited the test on the subject of Approach to a patient with a headache in the general practice setting with 50 questions. The test was created by Svetlana Simic, MD, Ph.D., and Miloranka Petrov Kiurski, MD, GP, MSc and it was used as a research tool for the needs of the Section of General Medicine of the Serbian Medical Society. We analyzed the answers to all fifty questions. The questions referred to solving clinical problems in patients with different types of headaches, by circling one of the offered answers. The test was passed if, at least, 60% of the answers were correct. The answers were analyzed in relation to GP`s gender and Serbian region where they worked. The data were processed using descriptive statistical method and presented as frequencies (%), X 2 test and one-way ANOVA were used to measure differences between variables. All the answers were processed with software statistical package SPSS 20. Statistical significance was defined at p<0.05 level.
To successfully pass the test it was necessary to give correct answers to at least 60% of the questions. The test passed 98.7% of the participants (Graph 1).
There were fewer correct answers to questions number 4,6,14 and 19. Question number 4 referred to migraine without aura treatment strategy, in a patient in the case report. Only 29.4% of the participants knew about the stratified therapy approach (Table 3). Analyzing correct answers we found no statistically significant difference, in relation to gender (p= 0,746) and the working region (p=0,183), (Table 2). Primenu strategije korak po korak, sa primenom najpre nespecifične a potom specifične antimigrenske terapije. Apply the step-by-step strategy, at first giving non-specific and then specific anti-migraine therapy c.
When treating acute migraine attack, 7.2% of the GPs would use antiemetics (Table 4). There was no statistically significant difference in relation to gender and the Serbian region where they worked (p=0.989 and p=0.627), (Table 2).  Indomethacin as a diagnostic-therapeutic test for the paroxysmal hemicrania was known to 38.4% of the GPs (question 14) ( Table 5). There was no statistically significant difference in relation to gender (p=0.960) but the GPs from Belgrade gave more correct answers when compared to their colleagues from Central Serbia and Vojvodina (p=0.000) ( When to initiate corticosteroid therapy in giant cell arteritis (question 19) was answered correctly by 57.4% of the GPs. (Table 6) There was no statistically significant difference in relation to followed parameters (gender, p=0,918, and region, p=0,124) ( Table 2).

Region/ Region
How much blood pressure should be lowered knew only 29.9% of the GPs. (Table 8) There was no statistically significant difference in gender (p=0,631) and working region (p=0,659) ( Table 7).  Based on the clinical presentation, given in the case report, only 31.7% of GPs correctly suspected an emergency, such as internal carotid artery dissection (Table 9) and there was no statistically significant difference in the given answers (gender, p=0.631, region p=0.659) ( Table 7). Tabela 9. Radna dijagnoza na osnovu kliničke slike kod pacijenta u prikazu slučaja Table 9. Working diagnosis based on the clinical presentation from the case report

Muški/Male
There were very few correct answers (38.9%) to a question about the choice of the diagnostic procedure to resolve the case. (Table 10) There was no significant difference in gender (p=1.000) but the GPs from Belgrade gave fewer correct answers compared to their colleagues from Central Serbia (p=0.002) ( Table 7).  Anticoagulant and symptomatic therapy, as the right treatment choice, were recognized only by 32.4% of the participants (Table 11). There was no statistical difference in GPs gender p=0.676), or working region (p=0,305). To the questions concerning headaches due to the nonvascular intracranial disorders, presented in the case reports of a patient with hypophysis tumor and a patient with intracranial neoplasm, we got 87.9% of the correct answers. (Table 12).

Region/ Region
Out of the total number of the participants, 83.3% correctly answered the questions about diagnostics and therapy in patients with bacterial meningitis (Table 15). There was no statistiacally significant difference in gender, but the GPs from Central Serbia made better judgment calls concerning clinical features indicative of meningitis (question 40) than their Belgrade colleagues. The GPs from Central Serbia were also better than their Belgrade and Vojvodina colleagues in noticing the most important differences between meningitis and subarachnoidal hemorrhage (SAH) (question 41). The "red flag" symptoms, indicative of the potentially dangerous headache, were better recognized by the Serbian physicians than their out of Serbia colleagues (question 42) (Table 15).
The questions from number 43 to 50 were about the diagnostics and therapy of the headaches due to medication use or discontinuation. There were 74.21% of the participants who gave correct answers to these questions (Table 16).
Additional diagnostics in a 16-year-old boy with a firsttime headache (question 43), although his physical exam was normal, would have been ordered by 39.6% of the participants, because it was the new-onset headache (Table 17).

Muški/Male
There were no statistically significant differences in gender and working region (Table 16).
There was a therapeutic dilemma in some GPs concerning the headache due to the discontinuation of coffee consumption (question 45). The dilemma was whether the patient should have been given 100g of caffeine, in order to stop the headache in an hour`s time. The correct therapeutic approach had 47.7% of the participants (Table 18). There was no statistically significant difference in gender, but the GPs from Central Serbia (p=0.015) had significantly better reasoning than their colleagues from Vojvodina (Table 16). Nećemo dati ništa, glavobolja će prestati u roku od sedam dana od potpune obustave kofeina/We`ll give nothing since the headache will go away on its own in seven days. c.
A headache due to medication overuse (analgesics i.e.) in patients with primary headaches (question 46) was recognized by 51.9% of the GPs (Table 19).

Discussion
Headaches are one of the most common reasons for visiting a doctor`s office, whether as a chief complaint or along with other health problems. A great many remain undiagnosed. A huge British study, which included a lot of participants 9,12 found 70% of the headaches are not classified, at all, 24% are diagnosed as primary, and 6% as secondary. 4 In our research only 1.6% of the GPs didn`t pass the test. To Pristup pacijentu sa glavoboljom u opštoj medicini Оpšta medicina 2020;26 (3)(4):43-58
Glavobolje uzrokovane prekomernom upotrebom lekova, najčešći su problem hroničnih glavobolja sa prevalen-questions on primary headaches, 74.44% of the participants gave correct answers. According to the Canadian Headache guidelines, migraines are the most common types of headaches in primary health care and they are underdiagnosed and undertreated. 5 In our study, there were fewer correct answers on the migraine without aura treatment (29.5%). In similar research, in Turkey, only 8.3% of the participants diagnosed migraine in their offices, and 55.6% said their academic education on migraine wasn`t sufficient. 6 An encompassing migraine therapy includes lifestyle changes, avoiding headache triggers, acute and prophylactic therapy, and patient`s education on migraine. 7 When to start corticosteroids in giant cell arteritis was answered correctly by 57.7% of the participants. Alzahrani`s study showed half of the physicians in their study were lacking knowledge in correct headaches treatment. 8 His study showed primary care physicians needed more education on headache treatment.
Steiner and al. suggest 90% of headaches should be resolved in primary health care but with the necessary education. They say such a model would enable the remaining 9% to be treated on the secondary health care level and 1% on the tertiary level. 9 GPs must recognize clinical symptoms, so-called "red flags" identifying life-threatening headaches. 10 In our research, 87.0% of the GPs recognized these "red flag" symptoms, indicating potentially life-threatening headaches.
Although primary headaches are the most common, one of the biggest challenges is diagnosing secondary headaches. 11 Analyzing correct answers for the different types of headaches we found a surprisingly low percentage of GPs (56.9%) who gave correct answers to questions about the headaches due to cranial or cervical vascular events. Although these are the most common secondary headaches in general practice. How much high blood pressure should be lowered, using medications, knew only 29.9% of GPs although there are the National guidelines for diagnosing and treatment of ischemic stroke. 12 Based on the clinical features in the case report, only 31.71% of the GPs correctly suspected an emergency such as internal carotid artery dissection. There were few correct answers (38.9%) on the subject of diagnostic procedures that would resolve the case. Only 32.4% found anticoagulant and symptomatic therapy as the right choice 8 . These results indicate there`s a need for further education of the GPs, so the patients with emergencies would receive proper medical care and relieve secondary and tertiary health levels.
The headaches caused by medication overuse are the most common chronic headaches with a prevalence of 1%-2% worldwide. 13 Whether these types of headaches appear in patients with primary headaches who overuse analgesics knew 51.9% of our participants. The majority of the patients with occasional tension headaches and migraines self-medicates with OTC painkillers, never consulting their GPs. It`s one of the reasons why medication-overuse headaches are so frequent. 14