Commentary: Controversies in SIGN guidance on diagnosing and managing headache in adults

doi:10.1136/bmj.a2445

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Giles Elrington, consultant neurologist

¹Barts and The London NHS Trust, London E1 1BB

elrington{at}aol.com

A discussion of headache centres on two largely independent areas: diagnosis of possible serious cause (usually none is found), and pain management (typically less, not more medication is needed). The newly published guideline from the Scottish Intercollegiate Guidelines Network (SIGN)1 uses the familiar split of primary and secondary headache—that is, benign and serious headache.

Secondary headache

It is unusual for headache to be the sole symptom of brain tumour.1 The guideline omits demographics: the approximate risk of brain tumour or other serious cause for headache is 1:1000 for headache presenting in primary care, 1:100 for headache presenting in secondary care (outpatients), and 1:10 for headache presenting in accident and emergency departments.

Imaging

The guideline lists familiar “red flag” indications.1 Reassurance from a scan is supported by a single, unblinded study showing benefit at three months but not at one year.2 The guideline discusses risks of imaging, not confined to computed tomography ionising radiation. Incidental …