A medical practice in the Durham area

3. Mr O complains the Practice’s GPs provided incorrect care and treatment for the severe headaches Mrs O experienced between 2014 and January 2020. He is particularly concerned they did not request further investigations or refer Mrs O to a specialist to investigate her headaches further. He complains GPs incorrectly advised Mrs O her headaches were migraines or caused by her menstrual cycle.

4. Mr O tells us Mrs O collapsed on 13 January 2020 and had emergency surgery for a ruptured brain aneurysm, and sadly passed away on 7 March 2020.

5. Mr O thinks had the Practice referred her for further investigations and for specialist input, her aneurysm would have been identified and she would have received planned surgery earlier. Mr O thinks Mrs O would have had a greater chance of surviving if she had surgery sooner.

6. By bringing his complaint to us, Mr O is seeking service improvements.

7. Below is a summary of the events we considered.

8. In January 2014 Mrs O presented at the Practice with headaches. The records document:

• she had experienced headaches for ‘many, many years’ • her headaches lasted up to four days • sleeping in a darkened room helped • her headaches were occasionally triggered by stress • the GP considered her symptoms were suggestive of migraines • Mrs O agreed to try treatment to prevent migraines and the GP prescribed topiramate 25mg (a medication used to prevent migraines).

9. In February 2014 Mrs O attended the Practice for a review of the effectiveness of the topiramate medication. The records document:

• Mrs O said her headaches were no better, she had experienced two episodes since her last attendance • Mrs O said over the counter pain medication helped and her headaches were worse when she was stressed at work • Mrs O said her menstrual cycles were shorter and therefore she wondered if she may be ‘going through the change’, referring to menopause • The plan was for her to continue trialling topiramate, to take pain medication as and when needed, and for the Practice to carry out blood tests and review her in a further two weeks • she had a blood test, and these were reported as ‘normal, no further action’.

10. In March 2014 Mrs O attended the Practice. The records document she had stopped taking topiramate and was feeling a lot better but her ‘migraine headaches’ were persisting. She said she was not keen on taking treatment to prevent migraines and preferred to take stronger pain medication during episodes to manage the pain. The GP prescribed sumatriptan (medication used to treat migraines and cluster headaches).

11. In February 2017 Mrs O attended the Practice to discuss headaches. The records document she had experienced headaches since stopping taking fluoxetine (an antidepressant medication) a few weeks before. She told the GP she was now experiencing headaches when she was menstruating.

12. In July 2018 Mrs O went to the Practice with headaches. The records document headaches had been an ongoing issue for around four years. Mrs O noted she was worried about her neck and wondered if she needed a head scan. The records document: ‘migraines tend to be worse during her periods as well. Unsure why and if she is going through the change.’ The GP recorded their diagnosis as ‘Tension-type headache…Migraine’. The records also document the GP discussed the tension that was triggering her migraines and that she may benefit from the trial of tricyclic antidepressants and a review in a month to establish if the medication agrees with her. They advised, if the medication does not agree with her, she should arrange to see a GP sooner. The GP prescribed amitriptyline 100mg tablets (a tricyclic antidepressant).

13. In August 2018 Mrs O attended to discuss her mood. The records documented: ‘tca [tricyclic antidepressant] helping with headaches. Has thought she should maybe go on HRT’. The GP advised her to take half a tablet if they are making her too drowsy and not to take HRT due to the headaches she was experiencing.

14. In September 2018 Mrs O presented to review her headaches. The records document her medication was working fine and she was feeling better in herself.

15. In November 2019 Mrs O presented with a concern about the headaches she was experiencing either before or after her periods. The records document her headaches were mainly in the frontal area or could move to her temples. She says she felt sickly with the headaches, but her vision was not obscured, and she was not experiencing eye discomfort in bright light. She had a plan to attend her opticians the following week and that her periods were regular and normal. The records also document she had a history of occasional palpitations and did not drink excessive tea/coffee/fizzy drinks. The GP checked her blood pressure and pulse. The GP’s diagnosis was headaches, possibly linked to hormones. They suggested Mrs O complete a symptom diary about her headaches and, if required, use medication to stop her periods and see if her headaches go away. They prescribed Medroxyprogesterone 10mg tablets (hormonal therapy medication) and sumatriptan 50mg. On 13 January 2020, Mrs O was taken by ambulance to accident and emergency where she was diagnosed with a brain aneurysm. She had emergency surgery for a ruptured brain aneurysm.

19. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications the Practice did something wrong.

20. In the Practice’s complaints correspondence, it said Mrs O did not fit the criteria for a neurology referral because she already had a likely diagnosis of migraines and had responded to treatment. She also did not have any 'Red Flag' symptoms.

21. The guidance relevant to this complaint is NICE guidance [CG150] ‘Headaches in over 12s: diagnosis and management’, 2012.

22. We considered the guidance that states when doctors should consider onward referrals or diagnostic tests when patients present with headaches.

23. The guidance states doctors should consider the need for further investigations and/or referral if patients present with headache and any of the following features:

• worsening headache with fever • Sudden onset headache reaching maximum intensity within 5 minutes • New onset neurological deficit • New onset cognitive dysfunction • change in personality • impaired level of consciousness • recent (typically within the past 3 months) head trauma • headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze • headache triggered by exercise • orthostatic headache (headache that changes with posture) • symptoms suggestive of giant cell arteritis • symptoms and signs of acute narrow angle glaucoma • a substantial change in the characteristics of their headache

24. The guidance also states doctors should consider further investigations and/or onward referral for people who present with new onset headache and any of the following:

• compromised immunity, caused, for example, by HIV or immunosuppressive drugs • age under 20 years and a history of malignancy • a history of malignancy known to metastasise to the brain • vomiting without other obvious cause

25. The guidance documents the diagnosis criteria for different headache types, including migraine headaches and menstrual-related migraine.

26. We examined Mrs O’s GP records in view of the guidance. The records document Mrs O discussed her headaches with the Practice on eight occasions between January 2014 and 13 November 2019.

27. Having reviewed these, we have seen no indications the Practice went against the guidance at any of these appointments. This is because the symptoms documented in the medical records meet the symptoms for migraine, outlined in the guidance. Our adviser told us it is more than likely Mrs O did have migraines and the aneurysm did not cause the headaches she experienced. This is because, as documented on the NHS brain aneurysm webpage, most aneurysms do not cause symptoms until they burst, and the symptom of a burst aneurysm is the sudden onset of a severe headache.

28. We also considered if Mrs O’s medical records document any symptoms listed in the guidance that require onward referral to specialists or for investigations. There is no record of Mrs O experiencing any of the symptoms listed in these parts of the guidance, alongside her headaches. For this reason, we have not seen any indications the Practice should have referred Mrs O on to a specialist or requested further investigations into her headaches.

29. There is no indication the Practice did anything wrong when its GPs treated Mrs O for migraine headaches and did not refer her on for further investigation of her headaches. We have therefore decided not to take further action on this complaint.

1. We have carefully considered Mr O’s complaint about the care and treatment the Practice provided to his wife, Mrs O, and we have seen no indication anything went wrong.

2. Mrs O tragically died on 7 March 2020 because of a brain aneurysm and Mr O has clearly been seriously impacted by his wife’s death. Having carefully considered Mr O’s concerns that the Practice should have done more to prevent her death, we found there were no indications the Practice did anything wrong.