Headaches – Causes and clinical management

Hello, I'm Michelle Henratty. Welcome to Sound Optometry, the podcast from Docket that provides high quality continuing professional development for GSE-registered optometrists. You can gain one CPD point by listening to this podcast and completing the short exercise on our website, Docket.info. This month we're going to be talking about headaches. Headaches are symptoms that we often come across in practice. After all, we've all had them. But there can be many different causes, both visual and non-visual, and their severity can vary massively. It's not always clear how concerned we need to be or what we should do next. What if we've missed something important? Something that could be the sign of a morocenist problem such as underlying health condition or even a brain tumor? How do you go about problem solving when patients have a headache? After all, it is a very non-specific symptom. A new CPD course is available on the Docket website, featuring an optometrist and a GP to help answer that conundrum. For this episode of Sound Optometry, we've invited them onto the podcast as well. We'll give you a guide on what to look out for when examining patients and when to refer them on. Later on, are we speaking to Nerf Charner, a doctor in London? We think optometrist can learn some valuable lessons on how GPs deal with headache symptoms. After all working in primary care, there is an intersection, isn't there? There's a sort of point where everything meets in the middle or should meet in the middle and we need to kind of work together around that. First up, let's hear about headaches from an optometrist's perspective. Joining me now is Hillary Hodgson, who works in Manchester, both in community practice, and at the University's teaching clinic. She's also an assessor and examiner at the College of Optometrists. Hello, Hillary. Hi, Michelle. How are you keeping? I'm very well, thank you. Well, apart from this cold, but you'll be glad to know that I don't have a headache. Good. Very glad. Okay, so if we could start for the benefit of the listeners, what would you say headaches are? Patients have such a variety of symptoms, but they have different ways of describing things. People have different pain thresholds, so while one person will come in with a headache that they can barely move from, somebody else will have an equally bad headache, but not really complaining of it so much. So I think it's such a broad range of headaches that we've got, but that can be anything that affects from the neck up. I suppose people will have headaches that affect the neck and the back of their head. People will have headaches that affect the front of their head and all those ranges in between. So it does encompass a huge amount of different complaints. Yes, and quite often we're trying to work out whether or not they are refractive-based or ocular-based, or whether they are something that's more related to their general health, like a cluster headache or a migraine, that kind of thing. And that's where I think, well, actually I'm not quite sure what's causing a headache. I don't think it's right. I'm going to refer you onto your GP. Absolutely. So thinking about headaches in practice, can you talk us through what you would do if a patient came to you and said, well, I thought I'd come in to see you because I've been getting the headaches and the GP specials should come to you first? Yeah. So I think the most important thing is a good experience in symptoms. That's vital really, and often with experience you can nearly judge what the problem is at the end of history, sometimes without having done all the other tests. Sometimes it would be glaringly obvious, you know, sometimes patients have a jaw problem that can result in bad headaches. One of the patients yesterday at the university, for instance, had a really bad ear infection. And since she'd had the ear infection, she was complaining of headaches. Obviously, the university students delve so deep into their history and symptoms that they questioned her at a length about these headaches. But when I came in and did it, it was obvious it was linked to the more recent illness she'd had. And of course, you can pinpoint and funnel the information that you're getting to see get to the right information in the bit sooner. Absolutely. With experience. And I think the big thing is to ask about when did they start? Where they are. How long they've been going on? Some patients will come in and they've been having headaches for six months. And others will have been having headaches for two days and they're maybe not as good at dealing with pain. And this is where the tolerances come into it, I think, that it can be such a variety from different patients. But I think the history, talking about where, when they come from, of key question I find is do you wake up with the headaches in the morning? So that will really separate out those refractive headaches that will develop during the afternoon, for instance, from the headaches that might be slightly more concerning, maybe more from a medical point of view. So you mentioned students taking the history of symptoms and diving quite deep. And certainly with the practices telling how old, with the younger generation of optometrist I see when they're floundering with their history of symptoms, they quite often start with that acronym LOFCY. So for those of us that weren't taught that university, can you just explain what that might be? Yeah. So it's looking at the location, the onset, the frequency of the headaches. The type is next, so you want to talk about the type of headache, is it a low grade, dull headache or a sharp stabbing pains that they might have? Because obviously the low grade is generally going to be a bit more refractive, the more stabbing the pains and the more severe pains, we're going to be a lot more concerned about. The students are very good and I think it's something that we could all learn from is greeting it on a scale of 1 to 10. So if we were to ask the patients to grade their headache, you know, the 2's and 3's don't really concern us, but if somebody's coming in saying their headache is 9 or 10 out of 10, that's something that we obviously need to really take quite seriously then. Next we've got S self-treatment, have they been taking paracetamol, have they been taking ibuprofen, do the medications actually help? Have they just been taking more breaks, have they found that taking a break helps with us? So that can be really useful to know if the paracetamol aren't helping, then they really there is something going on. And the effect it has on them, so how is it affecting their quality life, is it stopping them from doing what they need to do on a daily basis? And they go to work or have they been signed off by the GP who's signed them off for a while and then sent them on to us. And then the final thing which is the cherry on the cake, which do you refer to with the air effect, are there any any safe sheeted factors such as the air infection? Yes, or have you had a bump to the head or have you had, you know, concussion and things like that, you might have a lot of sports people coming in, young boys playing rugby or whatever that might have had a concussion, that they don't think to mention to you that could be an undiagnosed concussion obviously, could be quite a serious cause for headaches. And sometimes it's something that might just land in your testimony, chair. Yeah, I mean like you, I don't tend to use acronyms, I just tend to ask the questions, but Sony, I think that's quite a good acronym for people who are less experienced to give them a little reminder list if you like. Yes, yeah. So how do you think we should tailor our assessments and examinations in practice after taking history and symptoms? That's obviously the big thing that we need to start with, but what comes next? I think obviously knowing that the refraction is up to date is really important. Obviously we've got us maybe. People are coming pressed by up a little bit sooner. Our visual tasks have changed a lot over the past five years. People are working at home more, they're working on screens and they're probably working on screens a lot longer than they ever would have been before. You're not getting up to walk around to different meetings. Your meetings are on screen, so you're constantly staring at a screen. And I think that low level of press biopia is creeping in and becoming a needle off sooner. So of course that's going to cause a lot of headaches for people. So getting the refraction up to date is key in making sure the specs are up to date. There's a lot of patients I find wearing ready readers because they've sort of self-diagnosed this early press biopia, picked up a pair of plus ones which work to a certain extent, but they might have uncorrected cells which would be a big part of the issue as well. So getting the refraction up to date for me is key. But also looking at BV issues, I know a lot of optometrist aren't very confident about dealing with BV issues and we'll tend to think, "Oh, I refer to an orthoptist." But there is an awful lot that we can do just even in terms of figuring out whether there's decompensating forays going on and picking up on those sort of issues that won't have a refraction coming along with them, but a big decompensating exorforia can be a massive issue and really cause quite significant headaches for those patients involved. Yes, and I think when we're in practice, as a less experienced practitioner, you think, "Well, when a child's got a biopsychosis problem, are you quite confident in examining and perhaps coming up with an attempted diagnosis?" And what is likely to be done at the hospital or what is likely to be needed? People are quite confident with that because they can refer on. They've always got a safety net there, haven't they? But when it comes to adults, I think people do have less experience because it's less common and therefore feel more cautious. Yeah. And again, what you're saying about the early press by APL, that's quite funny because you don't need to tell me about that. I know all about that. And me. I've had a near-ad since I was 41. Yes. And actually, you mentioned about refraction, but actually getting a good pair of well-fitting spectacles that have been dispensed properly so they fit you correctly is also equally important. Absolutely. Because again, if they're not centered right, that could be creating a problem with a normally welcome-pissated exorforia. So, absolutely. And even down to things like antiguera coatings and people using screens all the time. And I find quite a lot of the younger patients in the 20s are very good about having Plano blue light glasses. They've bought them online. They've read up about them. And of course, there is no conclusive evidence about blue light from screens causing headaches there. And so, actually, if they think they're protecting themselves by wearing these glasses, they could actually be not doing the things that could help prevent headaches, which would actually make the situation worse. So, yeah. Yeah. So, Hilary, when the average person comes into practice for an eye examination and they're not quite sure what the link is between their vision and the headache, so when you're trying to explain this to a patient, how would you go about explaining it in a way they understand them, will be likely to take up your advice? First of all, I have a conversation about what their visual needs are, whether they're looking at a screen all day or whether they're sewing all day or driving all day and get their needs established, first of all, so I know what they're actually using their eyes for. And then that gives me a clue as to maybe why the headaches might be developing. Then I want to look at the refraction side of things. If they're incorrect in whatever field they're doing, that can obviously be cause for the headaches. And then I think, you know, if they are using a computer all day at home, whether they've got a window facing them that would give a lot of reflections that then they'll screw up their eyes and get a bit of glare. And obviously all that tension in the forehead all day can be resulting in quite significant headaches for people. Or if they've got reflections on their screen or reflections on their glasses, then cause them to have eye strain and those asthenopic symptoms that can also be part of the reason for the headaches. So sometimes it can be really quite simple, but I'll always explain to a patient that I'm going to be really nosy and ask them lots of questions to try and establish what might be actually happening. Yes, and it's putting the explanation to the context of their everyday life isn't it? So they can see, well, actually, yes, you're right. I do have that problem and this is what I can do to change it. Yeah. Okay. So if you are convinced that headaches are eye related, but not necessarily refraction or binocular vision related, how should we go about referring the patient? Do they refer direct to the hospitalised service or do you think it's better to go via the GP? I think it depends on your area. I think if the patient comes into me and says my GP has sent me, I will always want to communicate back with that GP so that they know what's been done in the eye examination. And of course, in your letter you can say what examinations you've done to exclude refractive or ocular cause, so they know what you've done. So they need to refer elsewhere to have those things done. And if they refer on top of the mology or to neuro-opthology again, those colleagues will then know what you've done as well and that will give them a starting point. Absolutely. Yeah. I think it's really important to make sure we do feel as part of our investigation and pressures as well, even on those younger patients where typically in practices where maybe there's pre-screening going on or initial exams going on where maybe under the age of 30 or under the age of 40 patients wouldn't routinely have pressures and fields done, that everything gets done because we've got to rule out every possible thing. And I think sometimes that can slip under the radar a little bit. And I think it's important to practice is to realise what you can do and understand where you are limited. It's almost talking about having a problem tripping over things or missing things in the core of their vision. Okay, the central field test may well have been fine, but it's important to put in your referral to the GP. Actually, although their field test was fine, our field machine only tests the central 24 or 30 degrees. Absolutely. But this is where we can even go back to basics and back to confrontation that I think a lot of people have sort of forgotten those all school tests, I suppose, for one of a better word, even though it does still come up as an ASCII station and top tip for any pre-wages out there, doing things like that can really give us a good idea as to what's going on as well. Yeah. And you mentioned sort of more general health sort of systemic problems. And again, the GP is the gatekeeper to that patient's health record. So I think even if you think it may be systemically related or you're not quite sure and you think they do need to be seen very quickly and you worry that actually the GP isn't the right person to go to. It's still good to keep the GP in the loop because the GP has all that information that they can add to that referral as it goes forward into secondary care. Yeah, absolutely. If it's something glaringly obvious that's a pathological issue, it would be straight to the hospital. But sometimes you get a gut feeling about things like this, don't you? Especially if you've been doing it a long time and you'll know whether there is something more medical going on where the patient does need to see the GP. Maybe they've got really high on control blood pressure and that's causing part of the problem and really it's the GP should be the first port of call in that instance. Something interesting that came from working with NAV is that some people might get headaches because of their medications. So obviously as optometrist, the patients will maybe have a list or they'll have their NHS app with the information on, but sometimes it can be the combination of how their medications work together or the dosages of their medications that might have a part to play in the headaches that they're experiencing. So this is again where back to the GP who as you said is the gatekeeper, they know what they're on, they know the dosages and they can do medication reviews to make sure that that's not the issue. Another interesting thing that I learned from NAV when we were developing the chorus is that he really likes information coming back from optometrist rather than optometrist just saying to the patient, "Go see your GP as a dismissive comment or writing on the record. I've advised the patient to see the GP if the symptoms persist." Actually writing a short note and saying, "This is what I've done. I'm fairly certain there's no issues from the eyes point of view back to you." I think it just matters as well, isn't it, if the GP has sent the patient to you in the first place, but I think good communication is really quite important. You know when you've examined a patient and you decide actually it's not refraction or bad clevis related and you think it is more around their lifestyle. Do you have a tentative advice around that because I know we're meant to be getting into the row of being more holistic practitioners, aren't we? Yeah, absolutely. I think sometimes patients will double it a lot to us, won't they? And then if they're stressed about things or sometimes it can be as simple as being dehydrated because of their work environment. Well, yeah, I do like to have a chat. Obviously, Michelle, you know I'm fairly chatty. And I do like having sort of a chat with the patients about lifestyle in general. I've found recently, just with the age I'm at, I've ended up having lots of menopause discussions with patients because of course they talk about medication and if you're going through the same thing, it's easy to empathise. And I've found that I've been having lots of chats about things like that and actually saying, well, maybe go and get that element of things sorted out because headaches can be a massive issue as the hormones change. So I have found myself as I said, getting into a more empathetic role to say, yeah, we all have those issues and maybe it's something you haven't thought about discussing with the GP. And that's been really well received by patients. Thank you, Hillary. That was a really great conversation. You're more than welcome. You're listening to Sound Optometry with me, Michelle Henratty. Today we're looking at how to deal with headaches and practice alongside Docky's new online course on the subject. To understand the symptoms at a more medical level and to find out what we can learn from how GP's deal with headaches, I'm now joined by Nav Charna. Nav works at a practice in South West London and he was the chairman of the National Association of Primary Care, all of which made him the perfect person to advise on the content in Docky's headaches course for optometrists. So hello, Nav. Welcome to Sound Optometry. Hello. Thank you very much for having me. So Nav, how would you define what a headache is? From a medical point of view, nine out of ten cases, those headaches are likely to be from a what you would call a primary cause. Primary basically means nothing else is causing the headache. It's being generated intrinsically by the nerves or the blood supply around the head and the neck. And so the commonest cause of primary headaches would be tension type headaches. And I think again, we would probably all be very familiar with what that feels like. A sort of tight band that develops around the top of the head typically which may get progressively worse during the course of a day or when we're under pressure or under stress. I guess that's why when we're asking the patients about headaches, you ought to know where on the headache hurts and how it hurts. Yes, and that's right. It's important to be quite clear about the type of pain that is being described. And the reason for that is that the other common cause of headaches that might present our people who suffering with migraine and their the characteristic features tend to be one sided headaches with typically a throbbing or a pulsing nature to it. And sometimes those headaches are associated with what we call an aura, a sensation really, something visual, maybe affecting speech, maybe affecting some sensation on the face that typically the aura precedes the start of the headache. Sometimes within a few minutes, sometimes it might be within an hour or so. And so if you get an aura and then the headache comes on, we're reasonably confident that we're dealing with somebody who may be suffering with migraine. And then the other primary headache, that's just worth mentioning, what we call cluster headaches, which are essentially a very, very severe form of perhaps in my words, a migraine type headache, but it coming in in rapid clusters, the pain is intense and often the patient with cluster headaches are very, very agitated. They can't sit still and it's incredibly incapacitating. And people often describe that as one of the worst pains you can have. So that would be another primary type headache. And then Michelle, I guess just moving on then from that, is a smaller percentage of headaches accords by what we call secondary factors, things where there's another reason why the headaches coming on. And I think we can all imagine what those are, people are often very worried that they have a brain tumour or that they have something seriously wrong inside their head as to why the headache is coming on. So from a medical perspective, we would need to be very carefully assessing people with headaches just to make sure that there aren't any secondary characteristics that headache which might need urgent attention. It is difficult though because headache can be quite non-specific and is such a common symptom. So trying to identify which headache falls into the 90% of benign sort of issues and the types of the potentially more serious must be very difficult. Well, I think it is and then we would need a careful history as we've discussed. But in addition to the headache, we'd be looking for any systemic features, Michelle, by which I mean, are there any other things going on, like weight loss or a fever or just generalised unwellness. You may not take much to note that in someone with a more serious cause for headache. And then the other thing that is often worth thinking about is the age of the person presenting with headaches and older people are of course more likely to have something as a secondary cause for their headaches. But the thing that we're talking about are headaches caused by raised intracranial pressure, Michelle, which may not always present very suddenly and it might be a more gradual onset, maybe over days, sometimes over weeks. And in those circumstances, it's worth thinking about some other characteristics of the headache. So it might be a positional feature to the headache. So worse in the morning, maybe headaches associated in that situation with feeling sick or nauseated or vomiting even, that would be something concerning to my mind. And also if someone's having headaches when they cough or sneeze as a result of a raised intracranial pressure, that would again prompt me to think that something more serious or sinister going on there. Well that makes sense because, and you've mentioned this already about age and secondary causes and of course, you know, over the age of 50, half of the population will be going through the menopause. And so again, you know, it's a secondary cause, not necessarily one that we have to worry about a lot, but it is something that is very significant to a lot of people and can actually cause quite debilitating migraine type of headaches because of the hormones. Yes, another common cause of headache, secondary headache is what we call medication overuse headaches. And I'm not saying that that necessarily applies to the types of people that you prefer to just now, but often people will take painkillers when they get headaches. And older people are of course more likely to have something as a secondary cause for their headaches. The prevalence of cancer might be higher in an older person, but equally, you know, over the age of 50, we're starting to think about are there other things going on? And you know, as we get a little bit older, there are conditions like temporal arthritis, also known as giant cell arthritis, where the temporal artery over the temples can get very inflamed. It can be very tender, it can pulse. And sometimes that can be associated with vascular changes, which affect the ophthalmic artery. And that can of course lead to loss of sight and visual changes. So, you know, we would worry about those sorts of conditions. The other thing Michelle just to be clear about is if there are neurological features associated with the headache, and by which I mean common things that people might recognise, like perhaps they've had a stroke. So there's a weakness of the face that there may be double vision. People might have had a fit or something unexpected happening neurologically, they may have collapsed. So, under those circumstances clearly we would be taking the headache symptom very, very seriously as to whether there's something else potentially underpinning that. And we should mention conditions where there's a sudden bleed into the brain, and the headache associated with that is sometimes called a thunder clap headache. It's a sudden explosion essentially inside the head. And I would be very unlikely that someone with a thunder clap type headache turns up to an optometrist. I think that would be unusual. But again, it's worth noting that. So often the first or the worst headache, if someone says that, you're kind of thinking, okay, hang on, we need to look into this a little bit. Yes, I've heard that phrase before. So, we talked about several types of headaches and different causes. Can you see a patient, and you think they're getting what we might call an everyday type headache or a tension type headache? What advice would you give them? How would you go about managing that patient? I think for me a consultation like that starts with getting clear understanding of what's concerning them, why they're worried, what the issues are, and often the worries are, is there a brain tumor, is there something more serious going on behind the scenes? So it's just understanding that, and then working through that with people often helps. You know, before you launch into lots of other things. And clearly in the story, there's a sense of trying to identify any triggers, any factors that might be linked to the tension, whether it's work-related stress, are there any other things going on in someone's life when the headache started. And then, you know, sometimes people will want some painkillers, and that's so hard to avoid, because what we're trying to do in that situation is avoid using regular cycles of analgesia. In the short term, maybe simple painkillers like paracetamol might be okay. But the most important thing is really just to help people understand what's going on, what the likely cause of headaches is having ruled out any of the more sinister causes, and then start to work with people to help address some of the psychological impact of those headaches before I think one of the reaches to prescribing medication. Yes. So you're trying to find the cause and eliminate the cause rather than just sticking a plaster of the top and hoping it will go away. Yeah. And reassurance, I mean, I don't want to be tried about this, but reassurance does help. You know, because people will have got themselves very worked up about the headache, and sometimes just going through the process of doing a proper assessment, making sure everything's okay, and then being able to reassure people with some suggestions as to how they might manage the headaches, going forward, you know, that in itself just works sometimes. And if you are worried about a patient and you are intending to send them off for investigation, how do you communicate that to them without worrying them even more? That's to be clear. If there's something potentially serious going on, then people need to be made aware that that's the case. So we need to prepare people for the fact that there might be something that needs looking at quite seriously. So that, you know, we need to be honest and clear to people that that's what we're concerned about, and make it clear that they're going to go through a process of investigation urgently. We have to make the impress the urgency of getting assessed as quickly as possible under those circumstances. So now, if a patient comes in to see an optometrist and we've done the eye examination, but we can't pinpoint an ocular cause for the headache that we can deal with, we'll usually want to refer onto the GP. So what do you want to see on a referral letter? Well, you know, I've had some very good examples for colleagues where they've written with, I think there's a standard form or a standard pro-former. Yes. So it shows what eye examination checks have been done. And then in the comments section underneath saying that this patient's stories of how long and that they're concerned about the following, the following checks have been done. And we couldn't find anything obviously wrong, but we've asked them to come and see you. And that in itself is really helpful, particularly if there's been a check for papalodema and things like this. The most helpful thing that I found, you know, where it sounded like it was a tension type headache was that they'd actually asked the patient to fill out a headache diary. And then the patient did pretend they'd done that. They'd completed the diary and that just made life so much easier. Yes, I suppose by putting into the referral letter what the patient's presented with and how we've investigated. Do you know what we've done or what we've managed to roll out, or even if we've done something and you think that's a significant piece of information, you can use that as a springboard to your next investigations. But headache diaries, it sounds like a really good idea. And Michelle, let me just emphasise again that we get a letter which is that the fund is not normal and they weren't any visual field effects. For me, that is an element of the assessment actually very, very helpful. Yes. So just before we finish off, if an optometrist cannot pinpoint, I wish really, a related reason for a headache. And even if there aren't any sinister signs, some optometrist would probably still tell their patient to go to the GP if they don't resolve just to be on the safe side. So what are your top tips around best practice in these circumstances? Obviously we don't want to send people unnecessary to the GP, but at the same time we're not quite ready to say, "Actually don't worry, everything's fine." So what advice would you give in that scenario? At the risk of getting a backlash from my GP colleagues about, you know, not what patients are turning up. I mean, I think it's absolutely appropriate an optometrist refers patients back to GP in that situation because as we said right at the beginning of this conversation, those patients do need a comprehensive medical assessment to make sure we know what the diagnosis is and what the likely potential treatments are. And until that's done, until we've ruled out, you know, definable secondary causes, etc., it's very hard to just need people hanging out there with no clear idea what's going on. So from that point of view, I would say if there's no clear reason, so no clear, ocular reason for someone's headache. And Michelle, you might need to help me out on this because I mean, to my knowledge, refractive errors. Of course they can cause headaches through eye strain and so on, but I would say that's relatively uncommon as a cause of headache. Would that be right on that? Would you agree with me on that? I think it depends on what the patient's doing. So it's usually a conjunction with a task that they're doing and the duration of the task and the environment that they're doing. It's a whole combination of factors that tend to cause a visually related headache. And I guess optometrist, when they tackle headaches, it's usually on the visual refractive by the eye of vision side, and then if it's not that, they then look for the sinister things, but the sinister things are usually scary things. But I think there's a whole section of patients that fall in between the two where they have a headache that we can't resolve as optometrist. They haven't got anything sinister like people to do, but they may have something else like systemic condition like hypertension. And that's why we need to refer to you, isn't it? So that's exactly the point that we've got to work together to ensure that those patients don't slip through the net, you know, so that they are referred back to us as quickly as possible because any contact with the GP practice will be triaged by someone and those patients can be appropriately seen in a timely way. And ideally, what would you like optometrist to take away from this podcast and also from the headaches course? So having a broader knowledge around a symptom, irrespective of who's doing what helps because you can frame the problem in the context of a broader knowledge and understanding. So if you have a good framework on how to look at headaches, how to assess them, even though you're only going to be looking at one tiny, perhaps part of that whole spectrum of things that cause headache, I think helps. The second thing I think is the one we've just been talking about, how we essentially build a primary care team and we're all working in primary care that supports and works together based on our respective skills, competencies, equipment, knowledge, understanding, you know, because there is an intersection, isn't there? Nath, thank you very much. Thank you Michelle for being so kind and generous in your questions. And thank you for listening. Make sure you go and check out the recently launched headaches course on our website, docket.info. There will be six parts and you'll be able to gain five non-interactive and one interactive CPD point. To access the first part of the headaches module, you can also follow the link in the podcast description. There are also the usual reading materials and resources as part of this episode on the Docket website. Go to docket.info and search for sound optometry and click your CPD point covering clinical practice and communication. Finally, make sure you hit subscribe on your podcast app so that you don't miss the next episode of sound optometry out in January 2026. That one will be all about vitro-machilla interface disorders. That's all from us this year. The producers are Jason Hoskin and Dr. Hillary Guides. I'm Michelle Henratti. Have a very happy festive period once it comes around. Thanks for listening.