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“The patient with a headache often finds himself a medical orphan. He is fortunate indeed if his headache is transient, for otherwise he may find himself on an excursion to the ophthalmologist, otolaryngologist, neurologist, dentist, psychiatrist, chiropracter, and the latest health spa. He is x rayed, fitted with glasses, analysed, massaged, relieved of his turbinates and teeth and too often emerges with his headache intact.” RC Packard 1979
Other than the most dedicated of superspecialists, all neurologists frequently see patients with headache. And yet headache has been, and perhaps is still, somewhat of a Cinderella area, with many myths perpetuated, and newer ones evolving. Faced with a patient with headache, the relevant questions are simple to ask, if not necessarily to answer (box 1). An accurate diagnosis almost always depends only on the history, and for most patients further investigations are supremely redundant—although many are investigated.
What headache patients most want is a comprehensible explanation of their symptom, which is perhaps the most important therapeutic step. This is a tricky task, especially when so little is understood about many headache syndromes, and many neurologists are not good at explaining concepts such as migraine or chronic daily headache. Far too often it is assumed that patients would like treatment and brain scans. Perhaps copying clinic letters to patients, and providing them with up-to-date review articles or useful websites, might help with our explanations.
To answer patients’ questions, one needs time and energy—which are often in short supply; there is a temptation to reserve those resources for patients with “proper” neurological disorders such as multiple sclerosis or stroke. Invisible symptoms, such as pain, may lead to a degree of disbelief in doctors (and others)—something patients are acutely aware of. Neurologists need to remind themselves of this when faced with the healthy-looking chronic …
Competing interests: Within the last 5 years, I have received honoraria for speaking or chairing meetings from various companies involved with headache treatments, including Merck Sharp & Dohme, Menarini, Janssen-Cilag, and Pfizer.