Profile of Chronic Headache Patients in the Asir Region: A Three-Year Study in Asir Central Hospital, Abha

Introduction

Headache is one of the most common symptoms encountered in general medical practice, accounting for about 4% of outpatient physician visits.¹ According to different population-based studies, over 70% of the general population experience at least one headache per year,² and about 15% consult a physician about this.³ Headache syndromes were the most prevalent neurological problem encountered in the Thugbah community survey of neurological disorders in the Eastern Province of the Saudi Arabia.⁴

The organization of health care systems and availability of resources in various communities influence clinical practice. Knowledge of the profile of headache patients in specific communities, therefore, facilitates rational utilization of health care resources in the investigation and long-term management of these cases. Most patients evaluated in the Neurology clinic of Asir Central Hospital (ACH), Abha, are referred by general practitioners, often from Primary Health Care Centers. This study was conducted in ACH to define the profile of patients referred to the Neurology clinic for chronic isolated headache, with a view to formulating a management strategy for this common condition.

PATIENTS AND METHODS

Patients seen specifically for headaches in the Adult Neurology Clinic of ACH, Abha, were prospectively enrolled in the study over a three-year period, beginning April 1995. Chronic headache was defined as one afflicting a patient for a minimum of two weeks. Inclusion criteria were that a patient had suffered chronic headaches and the referring physician had reported the neurological examination as normal. Non-Saudi patients were excluded. A detailed physical examination, including blood pressure measurement and fundoscopy, was performed. Relevant laboratory tests were requested, as indicated by clinical findings. Erythrocyte sedimentation rate was estimated in all patients aged 45 years or more. Although neuroimaging was not a requirement for inclusion in the study, all but nine patients had cranial computed tomography (CT) scans, mainly because they could not be reassured that a serious intracranial lesion was not responsible for their illness. One patient who had typical symptoms of polymyalgia rheumatica had temporal artery biopsy performed.

Headache was classified according to the International Headache Society Classification (1988).⁵ Headaches symptomatic of organic or structural disorder are referred to as secondary headaches, while dysfunctional headaches such as migraine and tension-type headache (TTH) are described as primary headaches. Follow-up was conducted in ACH for as long as required to reach a diagnosis and formulate a treatment plan.

The proportions of migraine and TTH headache patients with various clinical features were compared using chi-squared test.

RESULTS

Ninety Saudi patients, constituting 89% of the 101 headache patients of all nationalities seen during the study period, are analyzed in this report. The median age of the patients was 31 years, and the range 11 to 75 years. Sixty-eight patients (76%) were aged 20 to 49 years, while only four were 60 years or older. There were 64 females, resulting in a male to female ratio of 1:2.5.

The headache diagnosis in all patients is shown in Table 1. Primary headache was diagnosed in 79 cases (88%). Eleven patients had headaches symptomatic of a secondary disorder. A 75-year-old female, the eldest in the series, with bifocal meningiomas in the left supratentorial space, had experienced persistent left hemicranial headaches for 13 years. The other brain tumor patient was a 20-year-old female who had a pituitary tumor with suprasellar extension, and had gross clinical features of acromegaly with unilaterally impaired visual acuity. Neither of these patients had papilloedema. Hydrocephalus involving the ventricular system proximal to the aqueduct of Sylvius was diagnosed on brain CT scan in a 20-year-old female with papilloedema who had suffered daily attacks of pulsatile bitemporal and occipital headaches of 12 to 15 hours’ duration for two years. Polymyalgia rheumatica was satisfactorily treated with prednisolone 5 mg daily in a 50-year-old female whose temporal artery biopsy was normal, but who had an erythrocyte sedimentation rate of 75 mm in the first hour (Westergren) upon presentation. Headache of increasing severity in the week after spinal anesthesia brought the patient with lymphocytic (aseptic) meningitis and long-standing episodic TTH headache to the clinic.

Table 1. Headache diagnosis in 90 Saudi patients.

A comparison of migraine and TTH patients is shown in Table 2. The main differences between these groups were that migraineurs had a higher female to male ratio, onset of headache before 30 years of age in a significantly higher proportion (P=0.03), and experienced headache for more than two years significantly more often (P=0.005) than TTH patients. The duration of symptoms was less than a year in 10 TTH patients and in only one migraineur.

Table 2. Comparison of migraine and tension-type headache patients.

DISCUSSION

Primary headache disorder was diagnosed in the vast majority of patients referred to ACH for the management of chronic isolated headache. This finding and the preponderance of females patients are similar to previous reports.⁶ TTH headache has a higher prevalence (78%) than migraine (28%) in population-based studies.⁷ The slightly higher case frequency of migraine compared to TTH in this series may be explained by the selection bias inherent in referred hospital patients.⁸ Since migraine is associated with more intense headache than TTH, and by definition interferes with daily activities while TTH does not,⁵ migraineurs would be more frequently referred to a neurological service than TTH patients.

The median age and range of our migraine patients was similar to that of TTH cases. However, age of onset of headache was over 30 years in most TTH patients, and they had been symptomatic for a shorter period (<2 years), compared to migraineurs. The former observation is consistent with the reported peak incidence of migraine in the second and third decades.⁹ The shorter duration of headache disorder in TTH patients compared with migraine was unexpected, because milder symptom intensity would be expected to delay requests for medical attention. The stresses of life events with increasing age may be factors in the pathogenesis of TTH.¹⁰ Merikangas et al.,¹¹ however, found no evidence of associated anxiety or depression in TTH patients. Our observation therefore requires confirmation.

Four cases (4%), one of acromegaly, two of pseudotumor cerebri and one of probable aqueductal stenosis, were identified by clinical evaluation as requiring neuroimaging. One brain tumor diagnosis would have been missed without a CT brain scan. This patient’s age and persistent unilateral headache were definite indications to search for an intracranial lesion. Cranial CT scan as a secondary screening test for four of our cases (4%), aged 60 years or more, was considered reasonable clinical practice. Intracranial meningiomas and pituitary tumors are often diagnosed incidentally on neuroimaging or at necropsy.^12-14 Other abnormalities of intracranial anatomy, such as arachnoid and poroencephalic cysts, or thin films of hygromas in the elderly, may result in unnecessary neurosurgical consultation.¹⁵ It is prudent to consider the contribution of these lesions to the pathogenesis of a patient’s symptoms in specific cases.¹⁶ Indeed, the International Classification of Headaches recognizes an earlier primary headache diagnosis if the characteristics of a patient’s symptoms change or new clinical features of an intracranial lesion occur.⁵

Neuroimaging in the investigation of chronic isolated headache is controversial. Based on cost-effectiveness studies, routine neuroimaging for chronic isolated headache is unnecessary.^16,17 The yield from neuroimaging, though low, is not zero.^18,19 The dilemma is that many headache patients, even in the United Kingdom, which operates a family physician system, remain unassured after neurological consultation, and some may request further investigations.²⁰ In a health care system equipped to provide superior follow-up care, patients might accept reassurance reluctantly while neuroimaging is deferred until a change in their clinical condition warrants it.^15,19 Chronic headache which has not changed in character may, however, be associated with brain tumor.^21,22 Where neurological expertise is in short supply and follow-up is uncertain, the cost and inconvenience of repeated visits to clinics far removed from patients in the hope of a “cure” for chronic isolated headache, the economic cost of lost time and reduced effectiveness of performance at work,²³ and the anxiety engendered by a perceived potentially life-threatening ailment, may influence the need for earlier neuroimaging in the investigation of the headache patient. Probably reassured that an ominous condition was not the cause of their chronic headache, 18 (20%) of our patients did not return to the clinic for follow-up after cranial CT scans that were normal.

In conclusion, this study documents the profile of headache patients referred to ACH, Abha. Although most patients suffered from a primary headache condition requiring only clinical evaluation, cranial CT scan was often performed to reassure patients of the absence of an ominous structural intracranial lesion.