Headache diaries for the diagnosis and management of primary headaches and medication overuse headache

National Clinical Guideline Centre (UK)

A new version of this title is available

Update information - February 2020: A footnote was added to recommendation 1.3.17 on the potential risk of propranolol overdose in people with migraine who also have depression. November 2015: New and updated recommendations on the prophylactic treatment of migraine were added.

6Headache diaries for the diagnosis and management of primary headaches and medication overuse headache

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6.1. Introduction

Headache diaries are often recommended for people who have disorders that are intermittent. It is thought that diaries will be more accurate than recall and allow patterns of events to be more clearly seen. This can potentially be helpful to both the person with the headache and doctor. Headache diaries may be useful in self-management as they allow the person to identify any patterns and precipitating factors in their symptoms. Diaries may help people to better understand their condition as well be alerted to any changes in the regularity or severity of attacks and the effectiveness of new drugs that may be introduced.

The GDG considered it important to assess the evidence for headache diaries for people with headache rather than recommend them uncritically. They were interested in two aspects of headache diary use – an assessment of the use of headache diaries in diagnosis of headache and their potential to facilitate other aspects of care e.g. self-management or doctor-patient communication. These areas were assessed in two separate reviews.

6.2. Headache diaries as an aid to diagnosis

6.2.1. Clinical question

What is the clinical effectiveness of using diaries for the diagnosis in people with suspected primary headaches and medication overuse headache?

A literature search was conducted for diagnostic studies comparing the use of headache diaries to clinician diagnosis according to ICHD-II criteria¹⁰⁶, see protocol C.1.3.

No MID was defined for any of the diagnostic outcomes. The GDG were asked to review the evidence and agree the level of imprecision based on the confidence intervals around the effect size and absolute effect estimate.

6.2.1.1. Clinical evidence

See evidence table in appendix section E.1.3.

Three studies were identified¹⁸⁹^,²¹⁶^,²⁴⁷. Diaries used in the studies were diagnostic headache diaries. They were required to be filled in at the end of each headache day in two of the studies²⁰⁰^,²¹⁶ and on a daily basis in one study²⁴⁷. The diaries used were similar to one another in the recording of headache intensity, frequency, duration, location and associated symptoms.

Two studies²⁰⁰^,²¹⁶ included in the review were in populations who were already diagnosed with specific headache types, only one study was in an undiagnosed population²⁴⁷. It was not possible to pool any results due to the differences in diagnoses and populations.

Table 15

Headache diaries for diagnosis - quality assessment.

Table 16

Headache diaries for diagnosis– Clinical summary of findings.

6.2.1.2. Economic evidence

No relevant economic evaluations on the use of headache diaries for diagnosis of primary headaches were identified.

We estimated the cost of evaluating headache diaries in terms of time spent by the health care professional in doing this.

From the literature we found no data on the average cost or time spent by the GP or other health care professionals to evaluate the diary. The GDG experts estimated this additional time to be from 1 to 2 minutes and that diaries can be evaluated by any health care professional.

We combined the GDG estimates with the cost data reported in the PSSRU publication⁴⁵ to obtain the cost of the intervention (Table 17).

Table 17

Cost of evaluating headache diaries.

The cost of using headache diaries is estimated between £2.80 and £5.64 per person.

6.2.1.3. Evidence statements

Clinical

One study with 61 people recruited in specialist headache centres suggested that headache diaries have a sensitivity of 94% and specificity of 50% in the diagnosis of migraine without aura, but there is considerable uncertainty. [Very low quality].

One study with 61 people recruited in specialist headache centres suggested that headache diaries have a sensitivity of 72% and specificity of 72% in the diagnosis of migraine with aura, but there is considerable uncertainty. [Very low quality].

One study with 61 people recruited in specialist headache centres suggested that headache diaries have a sensitivity of 84% and specificity of 45% in the diagnosis of episodic tension type headache, but there is considerable uncertainty. [Very low quality].

One study with 61 people recruited in specialist headache centres suggested that headache diaries have a sensitivity of 21.5% and specificity of 100% in the diagnosis of chronic tension type headache, but there is considerable uncertainty. [Very low quality].

One study with 49 people with ‘difficult to diagnose’ headaches recruited in a university hospital suggested that headache diaries have a sensitivity of 84.5% and specificity of 75% in the diagnosis of migraine, but there is considerable uncertainty. [Very low quality].

One study with 49 people with ‘difficult to diagnose’ headaches recruited in a university hospital suggested that headache diaries have a sensitivity of 88% and specificity of 67% in the diagnosis of tension type headache, but there is considerable uncertainty. [Very low quality].

One study with 49 people with ‘difficult to diagnose’ headaches recruited in a university hospital suggested that headache diaries have a sensitivity of 78% and a positive predictive value of 100% in the diagnosis of chronic tension type headache, but there is considerable uncertainty. [Very low quality].

One study with 76 people with undiagnosed headache recruited in specialist headache centres suggested that headache diaries have a sensitivity of 92% and specificity of 58% in the diagnosis of migraine, but there is considerable uncertainty. [Low quality].

One study with 76 people with undiagnosed headache recruited in specialist headache centres suggested that headache diaries have a sensitivity of 75% and specificity of 58% in the diagnosis of tension type headache, but there is considerable uncertainty. [Low quality].

One study with 76 people with undiagnosed headache recruited in specialist headache centres suggested that headache diaries have a sensitivity of 75% and specificity of 86% in the diagnosis of medication overuse headache, but there is considerable uncertainty. [Low quality].

Economic

Using headache diaries for the diagnosis of the headache type has a maximum cost of £5.64 per person, based on the incremental time spent by the health care professional to evaluate the diary.

6.2.2. Recommendations and link to evidence

Table

frequency, duration and severity of headaches any associated symptoms

6.3. Headache diaries as an aid to management

6.3.1. Clinical question

What is the clinical effectiveness, and patients’ and practitioners’ experience of using diaries for the management of people with suspected primary headaches and medication overuse headache?

A literature search was conducted for RCTs assessing the effectiveness of headache diaries for the management of primary headache. The GDG agreed that this search should be widened to observational and qualitative studies if no RCT evidence was found (See protocol C.1.4).

6.3.1.1. Clinical evidence

See evidence table in appendix section E.1.3.

No RCT evidence was identified for the use of headache diaries as a management tool in primary headache. Therefore the review focuses on evidence from observational and qualitative studies of patient’s and practitioners’ experience of using diaries for management as pre-specified in the protocol (see appendix C.1.4).

Four studies were identified ¹³^,³⁷^,³⁹^,¹⁰⁸^,²⁰³ which reported patients’ and physicians’ experience of using headache diaries for the management of primary headaches. Three studies ¹³^,¹⁰⁸^,²⁰³ used surveys and the fourth study (reported in two papers)³⁷^,³⁹ used focus group discussions as methods of data collection. A customised quality assessment for qualitative studies (see Table 18) was carried out on the three studies and a narrative summary of the findings is presented.

Table 18

Headache diaries for the management of primary headaches - quality assessment.

6.3.1.2. Clinical summary of evidence

Porter et al. 1981²⁰³

Thirty eight percent of participants felt the diary was helpful and 8% thought it was a hindrance; 69% thought that it would be useful to their physicians. The average level of headache pain over the second two week period decreased in 54.2%, increased in 40.5% and remained unchanged in 5.1% of participants. The number of days with any level of headache increased in 41%, decreased in 22.6%, and remained unchanged in 36.3% of participants over the second two week period. Average level of negative feelings over second two week period increased in 41%, decreased in 50.4%, and remained unchanged in 8.5% of participants over the second two week period.

Baos et al. 2005¹³

Seventy percent of people reported being more satisfied with the level of medical care compared to before using the diary and 88% felt that the diary helped them communicate better with their physicians.

Ninety one percent of physicians felt that the diary helped them to communicate better with their patients and 100% felt that it enabled them to assess differences in pain intensity and disability across attacks within the same person. 46% of physicians felt a difference in evaluation and differentiation between headaches pre and post study and 68% felt that the diary influenced decisions regarding prescription medication for migraine.

Coeytaux et al. 2007³⁷^,³⁹

This study provided a narrative summary of the opinions of people regarding the use of a diary for the management of headaches.

Participants felt that the diary was useful and not overly burdensome, provided a meaningful expression of their level of pain and was useful in measuring pain severity and frequency. They also felt that it allowed them to see improvement of which they might have been otherwise unaware.

Jensen et al. 2011¹⁰⁸

The headache diary along with the clinical interview was found to provide adequate information for diagnosis in 97.7% of cases. Information from the clinical interview alone was found to be adequate for diagnosis in 86.8% of cases.

The study reported that 97.5% of people did not have any difficulty in understanding the diary and providing information. Participants evaluated the diary as being useful for making them aware of medication usage but less useful for understanding headache triggers or deciding when to treat their headache. Also, 97% of physicians did not report any difficulty in understanding the diary and interpreting the information. Physicians evaluated the diary as being helpful in diagnosing medication overuse headache and informing people about medication intake and regarded it as less useful in informing them about headache triggers.

6.3.1.3. Economic evidence

No relevant economic studies comparing the use of headache diaries with no diaries were identified.

Please see 6.2.1.2 for cost analysis of evaluating headache diaries.

Economic

Using headache diaries for the management of primary headaches has a maximum cost of £5.60 per person, based on the incremental time spent by the GP to evaluate the diary.

6.3.2. Recommendations and link to evidence

Table

to record the frequency, duration and severity of headaches to monitor the effectiveness of headache interventions

Publication Details

Copyright

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Clinical Guideline Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Publisher

Royal College of Physicians (UK), London

NLM Citation

National Clinical Guideline Centre (UK). Headaches: Diagnosis and Management of Headaches in Young People and Adults [Internet]. London: Royal College of Physicians (UK); 2012 Sep. (NICE Clinical Guidelines, No. 150.) 6, Headache diaries for the diagnosis and management of primary headaches and medication overuse headache.

Table 15Headache diaries for diagnosis - quality assessment

Condition diagnosed	Limitations	Inconsistency	Indirectness	Imprecision
Russell et al. 1992²¹⁶
Migraine with aura	Very serious ^(a)	No serious inconsistency	Serious ^(b)	Very serious ^(c)
Migraine without aura	Very serious ^(a)	No serious inconsistency	Serious ^(b)	Very serious ^(c)
Episodic tension-type headache	Very serious ^(a)	No serious inconsistency	Serious ^(b)	Very serious ^(c)
Chronic tension-type headache	Very serious ^(a)	No serious inconsistency	Serious ^(b)	Very serious ^(c)
Phillip 2007 et al. ²⁰⁰
Migraine	Very serious ^(d)	No serious inconsistency	Serious ^(e)	Very serious ^(c)
Tension-type headache	Very serious ^(d)	No serious inconsistency	Serious ^(e)	Very serious ^(c)
Chronic tension-type headache	Very serious ^(d)	No serious inconsistency	Serious ^(e)	Very serious ^(c)
Tassorelli et al. 2008²⁴⁷
Migraine	Serious ^(f)	No serious inconsistency	Serious ^(g)	Very serious ^(c)
Tension-type headache	Serious ^(f)	No serious inconsistency	Serious ^(g)	Very serious ^(c)
Medication overuse headache	Serious ^(f)	No serious inconsistency	Serious ^(g)	Very serious ^(c)

a: No randomisation of participants; Only people with a diagnosis of migraine included; small sample size.

b: Participants recruited from a specialist headache clinic; Only people with migraine included.

c: Wide confidence intervals observed for sensitivity and specificity, agreed by GDG to indicate imprecision.

d: Unclear randomisation; Participants did not all receive the same reference standard; participants not all included in the analysis (high loss to follow up).

e: Study included only ‘difficult to diagnose’ people which may have excluded other diagnosis of primary headaches; unclear whether already diagnosed.

f: Unclear randomisation; small sample size.

g: Study conducted in specialist headache clinic.

Table 16Headache diaries for diagnosis– Clinical summary of findings

Condition diagnosed	Sensitivity (%)	Specificity (%)	PPV (%)	NPV (%)	Quality
Russell et al. 1992²¹⁶
Migraine with aura	72.73%	72.00%	36.36%	92.31%	VERY LOW
Migraine without aura	94.34%	50.00%	92.59%	57.14%	VERY LOW
Episodic tension-type headache	84.21%	45.24%	41.03%	86.36%	VERY LOW
Chronic tension-type headache	21.05%	100.00%	100.00%	73.68%	VERY LOW
Phillip et al. 2007²⁰⁰
Migraine	84.85%	75.00%	90.32%	64.00%	VERY LOW
Tension-type headache	88.10%	66.67%	97.37%	29.00%	VERY LOW
Chronic tension-type headache	77.78%		100.00%		VERY LOW
Tassorelli et al. 2008 ²⁴⁷
Migraine	92.19%	58.33%	92.19%	58.33%	LOW
Tension-type headache	75.00%	58.33%	51.22%	80.00%	LOW
Medication overuse headache	75.00%	86.67%	60.00%	92.86%	LOW

Table 17Cost of evaluating headache diaries

Health care professional involved	Cost per minute of visit	Additional cost time = 1minute	Additional cost time = 2 minutes
GP	£2.80 ^(a)	£2.80	£5.60
Consultant	£2.82 ^(b)	£2.82	£5.64

a: Based on the cost of GP clinic per minute, including qualification⁴⁵.

b: Based on the cost per person-related hour of consultant medical including qualification⁴⁵.

Recommendations	Consider using a headache diary to aid the diagnosis of primary headaches.
Relative values of different outcomes	Sensitivity, specificity, positive predictive value, negative predictive value, and number of people diagnosed were extracted. The GDG considered that number of people diagnosed was of least value. The other outcomes were considered important in evaluating use of diaries, but the large confidence intervals meant that it was difficult to draw conclusions.
Trade off between clinical benefits and harms	The GDG agreed clinical history should remain the basis for diagnosis of primary headaches and the diary used as an adjunct only. Some people may consider the diaries burdensome to complete and therefore there may be some issues with compliance. This should be considered when deciding if a diary is an appropriate tool to use. Recall in a consultation may not be accurate so a diary can assist in diagnosis.
Economic considerations	Using headache diaries for the diagnosis of the headache type has a cost of £2.80 to £5.64 per person, which includes the cost of the additional time the GP or consultant spent during a consultation in order to evaluate the diary. The additional cost could be offset by the more accurate diagnosis of the correct type of headache, which is important to provide the most cost-effective treatment according to the recommendations in this guideline.
Quality of evidence	The quality of the evidence varied between low and very low. Outcomes were downgraded due to study limitations including small sample sizes, non-random methods of selection and all were conducted in tertiary care centre, therefore the evidence only relates to these specific populations. The economic evidence was based on a simple cost analysis.
Other considerations	The recommendation was based on GDG informal consensus due to the low quality of evidence available. Equality issues should be considered when developing and using headache diaries including; reading and writing skills, language and cultural differences. The diaries used in the studies were diagnostic headache diaries recording daily details of headache intensity, frequency, duration, location, associated symptoms and use of symptomatic medication. The GDG were aware of multiple diaries available both on line and from clinics which record the above information and may prove useful.

Recommendations	If a headache diary is used, ask the person to record the following for a minimum of 8 weeks: frequency, duration and severity of headaches any associated symptoms all prescribed and over the counter medications taken to relieve headaches possible precipitants relationship of headaches to menstruation.
Relative values of different outcomes	Sensitivity, specificity, positive predictive value, negative predictive value, and number of people diagnosed were extracted. The GDG considered that number of people diagnosed was of least value. The other outcomes were considered important in evaluating use of diaries, but the large confidence intervals meant that it was difficult to draw conclusions.
Trade off between clinical benefits and harms	The GDG agreed clinical history should remain the basis for diagnosis of primary headaches and the diary used as an adjunct only. Some people may consider the diaries burdensome to complete and therefore there may be some issues with compliance. This should be considered when deciding if a diary is an appropriate tool to use. Recall in a consultation may not be accurate so a diary can assist in diagnosis.
Economic considerations	Using headache diaries for the diagnosis of the headache type has a cost of £2.80 to £5.64 per person, which includes the cost of the additional time the GP or consultant spent during a consultation in order to evaluate the diary. The additional cost could be offset by the more accurate diagnosis of the correct type of headache, which is important to provide the most cost-effective treatment according to the recommendations in this guideline.
Quality of evidence	The quality of the evidence varied between low and very low. Outcomes were downgraded due to study limitations including small sample sizes, non-random methods of selection and all were conducted in tertiary care centre, therefore the evidence only relates to these specific populations. The economic evidence was based on a simple cost analysis.
Other considerations	The recommendation was based on GDG informal consensus due to the low quality of evidence available. Equality issues should be considered when developing and using headache diaries including; reading and writing skills, language and cultural differences. The diaries used in the studies were diagnostic headache diaries recording daily details of headache intensity, frequency, duration, location, associated symptoms and use of symptomatic medication. A temporal association between headache and menstruation is required for the diagnosis of menstrual migraine and using a diary can help to establish this. This is further discussed in chapter 7. The GDG were aware of multiple diaries available both on line and from clinics which record the above information and may prove useful.

Table 18Headache diaries for the management of primary headaches - quality assessment

Study	Population	Methods	Analysis	Relevance to guideline population
Porter 1981²⁰³	Well reported	Poorly reported	Poorly reported	US tertiary care setting with people seeking specialised headache care
Baos 2005¹³	Well reported	Adequately reported	Poorly reported	People with headache enrolled from primary care physicians’ group practices in 12 cities in Spain
Coeytaux 2007³⁷^,³⁹	Well reported	Adequately reported	Poorly reported	People with headache from a university based, tertiary care headache clinic who had recently participated in a RCT (USA)
Jensen 2011¹⁰⁸	Well reported	Adequately reported	Adequately reported	People with headache awaiting first consultation at specialised headache centres in 12 countries across Europe and Latin America.

Recommendations	Consider using a headache diary: to record the frequency, duration and severity of headaches to monitor the effectiveness of headache interventions as a basis for discussion with the person about their headache disorder and its impact.
Relative values of different outcomes	Any detail of patients’ or practitioners’ experience of using diaries in the management of primary headaches expressed in the studies reviewed was considered as of equal value by the GDG.
Trade off between clinical benefits and harms	Some people may consider the diaries burdensome to complete and therefore there may be some issues with compliance. This should be considered when deciding if a diary is an appropriate tool to use.
Economic considerations	Using headache diaries for the management of the headache type has a cost of £2.80 to £5.60 per visit, which is based on the cost of the additional time the GP spent during a consultation in order to evaluate the diary. The GDG considered the role of diaries in deciding on headache management strategy and the increased effectiveness derived from the most optimal choice.
Quality of evidence	The evidence was of low quality, based on questionnaires and surveys reported in three studies. The limitations of the studies included poor reporting of the methods and analysis. Two of the studies were conducted in tertiary care settings with one including people from a clinical trial and hence, were indirect to the target population in the clinical question. The economic evidence was based on a simple cost analysis where cost data were taken from a national source while resource estimates were elicited from GDG opinion.
Other considerations	The GDG used the evidence and their experience when considering the use of diaries. The GDG agreed that the importance of communication and understanding the impact of headache should not be undervalued and diaries played an important role in acknowledging this. Diaries can help in the legitimisation of headache. Equality issues should be considered when developing and using headache diaries including; reading/writing skills, language and cultural differences.

6Headache diaries for the diagnosis and management of primary headaches and medication overuse headache

6.1. Introduction

6.2. Headache diaries as an aid to diagnosis

6.2.1. Clinical question

6.2.1.1. Clinical evidence

Table 15

Table 16

6.2.1.2. Economic evidence

Table 17

6.2.1.3. Evidence statements

Clinical

Economic

6.2.2. Recommendations and link to evidence

Table

Table

6.3. Headache diaries as an aid to management

6.3.1. Clinical question

6.3.1.1. Clinical evidence

Table 18

6.3.1.2. Clinical summary of evidence

Porter et al. 1981203

Baos et al. 200513

Coeytaux et al. 200737,39

Jensen et al. 2011108

6.3.1.3. Economic evidence

Economic

6.3.2. Recommendations and link to evidence

Table

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NLM Citation

Table 15Headache diaries for diagnosis - quality assessment

Table 16Headache diaries for diagnosis– Clinical summary of findings

Table 17Cost of evaluating headache diaries

Table 18Headache diaries for the management of primary headaches - quality assessment

Porter et al. 1981²⁰³

Baos et al. 2005¹³

Coeytaux et al. 2007³⁷^,³⁹

Jensen et al. 2011¹⁰⁸