Investigating chronic headaches

To the Editor: Please find below my reply to Dr Rodgers' letter to my IJCP article ‘Managing chronic headaches in the clinic’. Dr Rodgers makes an important addition to our paper on the management of chronic headaches in the clinic. The specific condition of headache caused by hindbrain compression was not addressed in our article and I am pleased that this information is now available to the headache audience. We did recommend that the physician elicit whether the patient has had a head injury and, if so, to investigate this further. However, I do not agree with Dr Rodgers assertion that all patients with chronic headaches receive an MRI scan. In my experience, most patients with chronic headaches have a history of episodic migraine or tension-type headache. The transition to chronic headaches may occur naturally by a process of biological transformation or as a result of the overuse of symptomatic medications (1). In either case, treatment involves withdrawal of any offending medications, introduction of preventive and (strictly limited) acute medications and long-term follow-up to minimize the chance of relapse. Such patients do not require routine screening, which should be reserved for those with more atypical headaches, like those with possible hindbrain compression. There are many potential mechanical causes for chronic headaches, including injuries to the neck and the head. There is a wide literature on cervicogenic (neck) headaches (2), but much less on headaches caused by head injuries. Dr Rodgers' letter reinforces the need for collaborative investigations into the causes of chronic headaches, not the least of which is the expertise of our colleagues in neurosurgery for patients with a history of head injury.