Headaches are, for all practical purposes, a hidden epidemic yet are not considered a serious medical problem. Each year over 45 million Americans suffer chronic headaches. Pediatric headaches increased from 14% to 50% from 1972 to 1991. Headache sufferers spend over $2 billion on over-the-counter medications. Statistics shows 48% of women and 38% of men have tension headaches while only 18% of women and 9% of men have migraines.1
Even though the tension headache is more prevalent, for a variety of reasons the migraine surprisingly ends up being diagnosed. Some severity bias causes this slanting of diagnosis toward the migraine. However, the primary reason for misdiagnosis is that the tension headache is a cross-over headache (dental/medical). Family practitioners can open up their practice to a new huge volume of patients with tension headaches with an understanding of how to deal with tension headaches. The mixed headache should be shared between the orofacial pain specialist and the neurologist, while a complex migraine headache should still be referred to a neurologist. In many cases, the PCP can provide management for the tension headache in the local practice.
A large portion of patients suffer from headaches and some of them are so impacted by their headaches that they cannot work nor have a decent social life. Imagine the patient impact of successfully relieving headaches in every local practice. What if the difference in tension and migraine headaches could be determined in the time frame insurance allows for diagnosis (i.e., 12.5 minutes)? With this knowledge, practices could enjoy helping people become the master of their chronic pain. To help with this task is the little known orofacial pain specialty that successfully treats moderate to difficult tension headache.
The effect of headaches on people around the world is tremendous. If headaches were a new phenomena that suddenly appeared in world today, it would be classified as an epidemic. Headaches significantly affect the individual, the work force, the healthcare industry, and healthcare costs. Table 1 provides some statistics about headaches. Some headaches are transient, benign, and infrequent; but some are frequent or intense enough to impact the quality of life. Many women have been told they have to just suffer, some are told they are stressed out females; others have run the gamut of triptans and resigned themselves to a life of pain. In many cases, headache sufferers begin, or are left with, home remedies to manage headaches.
In fact, headache suffers spend over $2 billion on OTC medications. Headaches cost American businesses approximately 150 million days of lost productivity adding up to $12 billion in direct or indirect costs. Unfortunately, only 5% of patients seek medical care for headaches in the primary care setting—yet 10% of emergency department visits each year are for headaches. Headaches are the seventh leading cause of ambulatory care accounting for over 18.3 million outpatient visits per year.6
Most primary care physicians (PCP) will attest that the diagnosis of headaches is difficult. This difficulty is complicated by: third party interference in healthcare, lack of visual symptoms, patient communication problems, limited curriculum in medical schools, evolution of headache science, pharmacological influences, medical-dental communications, patient biochemical differences, pain threshold differences, scientific and literature bias among others.
This article will discuss ways to:
- Diagnose headaches more effectively
- Reduce patient’s suffering from headaches
- Reduce the time from diagnosis to treatment
- Increase the success of headache therapy.
Acute vs. Chronic Pain
In a busy practice, it is always difficult to find enough time for all the pathologies and problems that are presented. Most hope that all patients will have easy, classic, straight-forward diseases or pains that can be diagnosed in the limited time allotted. When collecting patient data, symptoms, history, and clues, there is usually only enough time for the acute pains of the world.
Acute pain, with its primary sensory presentation (visual clues) and described by a good communicator (patient articulates symptoms), is amenable to a quick diagnosis. An acute pain such as a sinus infection, ear infection, abscessed tooth, skin rash, or cough-fever-congestion is amenable to a 12.5-minute diagnosis (time allowed by insurance companies). The primary sensory presentation speeds up the diagnosis. A chronic pain such as a headache, on the other hand, lacks a primary sensory presentation and so requires more time to obtain the history, symptoms, clues, and data. Without a prior relationship with a headache patient, it is difficult to identify the level, type, or quality of pain, frequency, duration, location, or any other associated symptoms.
Poor or Limited Clues (Symptoms)
The diagnostic process is complicated by the patient’s inability to identify symptoms, relate cause and effect, differentiate reactions, notice changes, and communicate this data effectively. In some cases, patients may have poor observational abilities, are histrionic, have unstable bipolar disorder, have a fragmented mind-body connection, or some hidden agenda. A thorough knowledge of the various pathologies, along with an understanding of patient differences and a determination to ferret out the information, is required with these patients. Where does it hurt? When does the head begin hurting? What part of the day does it hurt? Describe the pain?
“The diagnostic process is complicated by the patient’s inability to identify symptoms, relate cause and effect, differentiate reactions, notice changes, and communicate this data effectively.”
An answer such as “I don’t know” frustrates the process when you only have minutes to make a diagnosis. When the patient’s agenda is not to get better, the data provided is driven by other purposes. Some of the hidden agendas may include drug seeking, being entitlement driven, or having control issues. These issues color, flavor, or corrupt the information and makes the diagnosis difficult. A drug seeker will elevate the level of pain reported in order to obtain more powerful opioids. A patient with entitlement designs will report that nothing works on their pain except a little green pill (money). A spouse, who for years has been abused or neglected, may use guilt and disease to keep the husband (or wife) doting on them.