Diagnostische Strategien bei Patienten mit Kopfschmerz in der Hausarztpraxis. Eine qualitative Untersuchung.

Background: The symptom headache is a common reason for consultation in primary care and has a large range of underlying causes. The differential diagnosis of headache poses considerable challenges for the primary care physician. Patient history and clinical examination are especially for primary headache the most important diagnostic tools. The aim of the study was to analyze the diagnostic approach of primary care physicians in patients with headaches. Methods: 15 primary care physicians from rural and urban regions were asked to elucidate their personal diagnostic proceedings and concepts of the symptom of headache during semi-structured Interviews. Interviews were recorded and transcribed verbatim. After development of a coding system, qualitative analysis was conducted by two independent researchers. Results: Due to the high prevalence of the symptom and the wide range of possible underlying causes, primary care physicians consider the diagnostic workup of headache patients as a genuine general practice task. Hereby diagnostic workup is considered as a permanent tightrope walk between watchful waiting on the one side and fast acting in case of avertable adverse outcomes on the other side. Avertable adverse outcomes are identified by specific warning signals like neurological abnormalities and discrepancy heuristics. Therefore the statement „the pain is new“ was particularly alarming, a known pain is rather reassuring for the physician. Watchful waiting was attached an important value after exclusion of avertable adverse outcomes, because headaches often disappear spontaneously. In these cases a precise diagnosis is not relevant for the general practitioner. The test of treatment was often used as both a diagnostic tool and a method of watchful waiting. The participating doctors had different diagnostic reference patterns for the symptom headache that they were comparing with the presenting pattern of the individual headache patient. Doctors already used special key words and nonverbal information derived from the behavior of the patient as diagnostic markers early in the diagnostic process. The doctor’s knowledge of the past history of an individual patient together with the physician’s own often long-lasting professional experience played a particularly important role. Deviances from the diagnostic scheme occurred when the patient narrative including nonverbal communication was not conform with the classic reference patterns. Doctors often recognized this intuitively. Therapy failure, remaining uncertainty and lacking improvement after a period of watchful waiting were reasons for further diagnostic steps, mostly in the form of a referral to the respective specialist. The primary care physicians have developed different strategies to meet the fear of the patient that a brain tumor could be the reason of their headache Migraine was mostly diagnosed by accumulation of different diagnostic criteria such as unilateral pain, light avoidance and extensive accompanying vegetative symptoms. In the diagnosis of tension-type headache the doctor’s knowledge of the past history of an individual patient was particularly relevant. Cervicogenic headache and psychosomatic components of the respective headache patterns were two important points for many doctors. Conclusion / Implication: Key criteria for the diagnosis of the symptom headache were the personal experience of the respective primary care physician and the doctor’s knowledge of the past history of an individual patient. Doctors had different reference patterns composed of anamnestic key words and nonverbal information that were compared with the patient. The physical examination often did not play a prominent role.