New Delhi : Dr Anita Krishnan, Consultant Neurologist, Divisional Clinical Director, The Walton Centre NHS Foundation Trust spoke to ETHealthWorld’s Prathiba Raju on how headache is a high-impact global disorder and one of the most common referrals in neurology service and forms. She cautions that frequent use of painkillers for headaches causes additional medication-induced headaches. Indicating that a new artificial intelligence-based chatbot has the potential to diagnose and treat headaches precisely.
Why do headaches need to be taken seriously and how does it impact general health?
Headaches are very common and it is a high-impact global disorder. The Global Burden of Diseases estimates that approximately half of the world population- that is approximately four billion people suffer from headaches regularly. Three per cent have chronic daily headaches without a break which is a very distressing and disabling condition.
It may come as a surprise that migraine is one of the most common headache disorders and ranks second among the world’s causes of disability. It is the topmost cause of disability and lost days at work among young women.
Almost all headaches that are moderate to severe in intensity and affect the capacity of a person to function normally, can fall under the category of migraine. Few migraineurs (only 1 in 5) get flashing lights/wavy lines or pins and needles or weakness (‘migraine aura’) as part of their migraine. It is also very common to have a feeling of pressure behind the eyes, neck pain, visual blurring, fatigue, lack of concentration, word finding difficulties, dizziness, nausea etc with frequent headaches. So, migraines and other headaches cause significant disability and difficulties to sufferers on account of the pain as well as other accompanying symptoms.
What kind of headaches need immediate clinical assistance?
Certain ‘red flags’ point to sinister causes of headache- these pointers are usually in the description of the headache given by the patient and the clinical examination findings. New headaches that are explosively severe right from the onset, headaches associated with features of meningitis, headaches with double vision or persistent loss of vision, and new headaches in the elderly or those with a history of cancer require further urgent investigations like scans.
What is the current scientific understanding of headaches?
Contrary to popular belief, headaches are not always from a physical abnormality of the brain or other parts of the head and neck. 99 per cent of headache disorders in the general community are ‘primary headaches‘- these are genuine, troublesome headaches, that arise because of dysfunctional pain signals from an inherent headache system present within the human brain. Migraine, cluster headaches, and tension headaches are all primary headaches. Primary headaches do not require investigations. Investigations are warranted for headaches with sinister red flags.
In the past, headaches were stigmatised or even dismissed as a psychological disorder or as arising from sinuses, eyes, teeth, neck etc. Since the discovery of the neural pathways within the brain that create headaches, researchers have successfully identified the neurochemicals that are involved in these systems within the brain. This has led to the development of targeted treatments both for pain control as well as prevention
Many people use painkillers when it comes to headaches. Are there other treatments available?
Specific painkillers can be taken right at the onset of a headache attack to get partial or complete pain relief. But unlike other painful conditions, it is not advisable to take regular painkillers for headaches. The worldwide recommendation for migraine is that patients should not take painkillers more often than 2- 3 days a week. The use of frequent painkillers causes additional medication-induced headaches. This is one of the risk factors for developing a condition called chronic daily headache.
If someone is suffering from headaches more than twice a week, then they should be on to a separate set of medications called preventatives. These must be taken regularly because they function by trying to quieten the pain signals. Many preventatives are available as tablets and injections. It has to be noted that they have to be given a couple of months to start taking effect and have to be continued for 6-12 months for effective treatment.
What are the common pitfalls when it comes to headache management?
We all are used to pain representing a physical abnormality like an infection or a fracture- so it can be difficult to accept the concept of primary headaches and that there is nothing physically wrong with the brain. So often people undergo repeated brain scans unnecessarily. More than scans, it is the description of the headache attacks and associated symptoms that gives doctors the necessary information to come to the diagnosis.
Many are not aware that headaches can manifest in an episodic format (one-off severe headaches with long clear gaps until the next attack) or as chronic headaches (frequent severe headaches 2-3 times a week with a dull head fog/hangover-like feeling in between attacks).
We also suspect that ‘tension headaches ‘are overdiagnosed and most headaches that make patients seek medical help are migraines. Painkiller use is different in headaches when compared to other conditions that cause pain. Taking painkillers more than 2- 3 days a week or taking strong painkillers that contain codeine morphine etc are not advised as they make headaches more chronic.
What is the difference between tension headaches and migraine? What are the precautions that should be taken?
Tension headaches are dull headaches affecting both sides of the head around the front and the back that do not have any other accompanying symptoms, nor should they affect the patient’s day-to-day functioning. The feeling of pressure or tightness does not make the diagnosis of tension headaches. In contrast, migraine headaches, even a single attack, will almost always affect the person such that they cannot work efficiently, and they feel the need to rest or sleep. Both these types of headaches can co-exist.
A regular sleep pattern, staying well hydrated by drinking water, regular eating habits, and cutting down caffeine use are all strongly recommended for the overall control of headaches, especially chronic headaches. It is not necessary to follow specific diets for controlling headaches.
Headaches being a common symptom of COVID-19, what kind of impact does it have on patients, particularly for people who suffer from long COVID?
Headaches can happen spontaneously or be triggered off by illness, busy lifestyles and erratic sleep patterns, dehydration etc. Many patients with viral illnesses like COVID, describe a chronic headache disorder that feels like pressure or a ‘head fog.’ If the neurological examination is normal, these headaches are again likely to be primary headaches. The impact and management of these are similar to how we manage chronic migraine.
How will the new conversational AI chatbot developed by NHS, UK in partnership with Tata Consultancy Services (TCS) help patients and specialists and how is it going to speed the diagnosis and treatment process? What is the difference the chatbot is going to bring in from a normal consultation?
The Walton Centre NHS Foundation Trust is a specialist hospital trust in the UK, dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services. We serve a catchment area of 3.5 million people across Merseyside, Cheshire, Lancashire, Greater Manchester, the Isle of Man, North Wales and beyond with service partnerships with 18 NHS hospitals. Headache is one the most common referrals into the neurology service and forms nearly 40 per cent of outpatient referrals. We have already developed comprehensive pathways and guidelines that advise patients and general practitioners on headache diagnosis and management.
From the discussion so far, you can see that asking the right question is very important in differentiating between sinister headaches and primary headaches. Also based on the description and the pattern, the management will be varied. Many different treatments are available these days – provided the headache type is correctly diagnosed.
In our existing model, patients are referred to the service and wait till they are allocated an appointment to then go through the history and get management advice. The AI headache chatbot is being developed with bright minds in TCS and clinical input from our side. A patient referred with a headache is taken through a series of relevant questions and possible answers in the chatbot. Based on the answers the patient inputs, the chatbot builds the profile and pattern of the headache disorder including diagnostic features and trigger factors. This has immense implications in triaging referrals efficiently, ensuring patients are allocated to the appropriate clinic within the indicated time frame and given appropriate advice. This would mean that the first consultation can be spent on providing treatment and other advice thereby improving efficiency and quality of patient experience. The role of the chatbot has the potential to be extended further to other aspects of headache management.