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I’ve got a headach
e???
HeadacheDavid KernickExeter Headache Clinic
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Migraine impact Headache in top 10 of WHO disability index.
20% population – headache impacts on their quality of life (adults and children)
£3 billion per year in economic terms
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When people come to see you what do they think they have?
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When people come to see you what do they think they have?
Need glasses
Blood pressure
Brain tumour
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What do patients have when they present to GP with
headache?
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What do patients have when they present to GP with
headache? Landmark Study
85% migraine
10% Tension type headache
5% secondary headache
<1% other types of headache
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What do GPs think when patients present with headache? (Kernick 2008)
02
04
06
08
01
00
Pe
rce
nta
ge
20 40 60 80 100Age
Cluster MigraineTension Secondary
Undifferentiated
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Headache consultations in primary care
Consultation rates are low. 50% of migraine sufferers have never seen a doctor
10% are under continuing care
One third of headaches will be incorrectly diagnosed.
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What is happening in primary care?
Less than 20% will receive Triptan
Walling 2006
10% of those who would benefit from prevention receive it Rahimtoola 2005
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Headache referral patterns
9% GP presentations are referred to secondary care (25% children)
(Loughey)
20 - 30% of neurology referrals are for headache
(Hopkins)
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What do patients have when they present to A and E with
headache? Valade 2000
n – 9480
Average age 37
250 admitted (3%)
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Migraine 55% TTH 25% Cluster 7% Trauma 1.6% Trig Neuralgia 1.6% Sinusitis 1.6% Vascular disorders 1.2% Low Pressure 1.2% Meningitis 0.35% Tumour 0.17% Other Misc < 5%
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Case 1 35 year old male Three week history Sharp, severe pain bilaterally and posteriorly
lasting 10 seconds repetitively.
One question? Two examinations? Would you investigate?
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Classifying headache
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Where does the pain come from?Intra – cranial (dural pain fibres)
Tension – raised intracranial pressure
Compression – tumour
Inflammation - migraine,meningitis,blood
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Where does the pain come from?Extra - cranial
Arteritis Neuralgia Muscle tension Facial structures
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IHS Headache classification Primary Secondary
Migraine Tension type Autonomic cephalalgias
(cluster)
Traumatic Vascular Non-vascular (SOL) Substance induced Infection Disturbed homoestasis Facial structures
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Activation anywhere in the system can lead to output in any other part of the system and vici versa
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Thalamus +Mid Brain structures
Medication overuse headache
Tension type headache
AURA
CERVICALNUCLEI
MIGRAINECENTRE
HypothalamusCLUSTER
Headache model
Secondary Headaches
Primary Headaches
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Case 1 35 year old male Three week history Sharp, severe pain bilaterally and posteriorly
lasting 10 seconds repetitively.
One question? Two examinations? Would you investigate?
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Two examinations
Fundoscopy
BP
Giles Elrington neurological examination
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Case 1 35 year old male Three week history Sharp, severe pain bilaterally and posteriorly
lasting 10 seconds repetitively.
One question? Two examinations? Would you investigate?
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Headache Pathway
EXCLUDE A SECONDARY HEADACHE Do something now Do something soon
DIAGNOSE A PRIMARY HEADACHE Exclude medication overuse and manage the
primary headache
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Case 2
You are called out to a 21 year old female who has had severe sudden onset headache. She is lying in a darkened room vomiting and is unable to move.
What is the differential diagnosis?
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Sub Arachnoid - thunderclap headache
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Thunderclap headache - RVS
lasts 1-3 mths.
Primary or secondary
Normal CT, LP. Needs CT angio.
Can get complications
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Meningitis
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Malignant hypertension
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Migraine - The emergency call out
Injectable sumatriptan
I.M. Diclofenac and anti-emetic
Avoid opiates
Sort out the migraine
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Case 3
55 year old male.
New headache. L temporal. Fluctuating in intensity. Featureless. Examination normal.
What would you do?
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•Can be bilateral•Systemically unwell•Tender artery with allodynia•CRP better than ESR•Problem with skip lesions
Temporal arteritis
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CASE 4•26 year old pole dancer•Headache with intercourse•What questions would you ask her?•Any investigations?•Treatment?
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Sex headache
Pre orgasmic or orgasmic (10% SAH) Primary or secondary (vascular, tumour,
Arnold Chiari) Low threshold for investigation Treatment Technique B blocker Indometacin Avoid recreational drugs
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Non specific headache Tinnitus Two examinations What is most likely diagnosis?
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Low Pressure Headache
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Case 5A 34 year old man presents with pain around his left eye that he describes like a “red hot poker”. He has had a number of attacks over the last few weeks.With this presentation, what are the key questions you need to ask him to establish a diagnosis?What investigation will you do?
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Cluster - Autonomic Cephalopathy
High impact ++ Peri-orbital clusters 15mins - 3 hours Cluster attacks and periods Unilateral autonomic features Acute or chronic
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Cluster treatment
Injectable Sumatriptan
Nasal Zolmitriptan
Short term steroids
Oxygen 100%
Verapamil
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CASE 6
45 year old female Dull continuous bilateral occipital pain Featureless Worried as friend had brain tumour and wants
a scan
Three questions? Do you investigate?
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Have you ever had migraine?
Do you have problems with your neck?
What pain killers are you taking?
To scan or not to scan?
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Medication overuse headacheMedication overuse headacheH
eada
che
inte
nsit
yH
eada
che
inte
nsit
y
Migraine attacksMigraine attacks
Frequent ‘daily’ headachesFrequent ‘daily’ headaches
Withdrawal of all analgesiaWithdrawal of all analgesia
Return of episodic Return of episodic headacheheadache
Increased frequency of headache, Increased frequency of headache,
associated with increased frequency associated with increased frequency of analgesia use.of analgesia use.
Daily headache with spikes of more severe pain
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Primary Tumours
Meningioma 20% - 10 yr survival 80%
Glioma 70% - 5yr survival 20%
Misc. 10% - Variable
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Headache and tumour
Headache prevalence with tumour 70%+
Headache at presentation 50%
Headache alone at presentation 10%
(Iverson 1987)
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Risk of brain tumour with headache presenting to primary care (Kernick 2008)
Risk %
Undifferentiated headache
Primary headache
Under 50 0.09% 0.03%
Over 50 0.28% 0.09%
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We need to scan when the advantages out way the
disadvantages
Reassurance, Cost, exposure Diagnosis/treatment incidental pathology
(4-10%)
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Luftwaffe pilots (n-2370) Weber 2006
93% normal (25% variations of norm)
6.7% abnormalities
56 cysts; 13 vascular abnormalities;4 adenomas; 4 tumours
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In reality the inputs are complex
Limited poor quality evidence base Expert opinion Medico-legal case law Patient-doctor characteristics and
approach to uncertainty Organisational factors
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Probability of significant morbidity or mortality >1%.Need urgent investigation
Abnormal neurological symptoms or signs
New seizure
History of cancer elsewhere
Red Flags
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Headache presentations where probability is likely to be 0.1% and 1%. Need careful monitoring and
low threshold for imaging
Aggregated by Valsalva manoeuvre Headache with significant change in character Awakes from sleep New headache over 50 years Memory loss Personality change
Orange Flags
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The delivery of headache services
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Secondary Care
“The role of the specialist is to reduce uncertainty, to explore possibility and to marginalise error.
Primary Care
“The role of the GP is to accept uncertainly, to
explore probability and to marginalise danger”.
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GPs with special interest
NHS plan calls for GPSIs to provide local, efficient care
Controversy over concept from primary care
Limited evidence base
Substitution, complementation, meeting unmet need
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Commissioning headache service delivery
BASH 2001, ABN 2010
GPs first line management
GPSI support
Tertiary headache centres
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CASE 7
Jane is a 28 yr old Presents with a visual disturbance
lasting 30 minutes. No other symptoms What are the key questions? What is the differential diagnosis
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Thalamus +Mid Brain structures
Medication overuse headache
Tension type headache
AURA
CERVICALNUCLEI
MIGRAINECENTRE
HypothalamusCLUSTER
Headache model
Secondary Headaches
Primary Headaches
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CASE 7a
Jane develops a pattern of visual disturbance followed by headache
What features would confirm a diagnosis of migraine?
How would you manage the acute attack?
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Migraine
Prodrome 60% Aura 30 % Headache (30% bilateral) Postdrome
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Formal Migraine
At least 5 attacks 4-72 hours (1-72 hours) Two of : unilateral, pulsating, moderate or
severe pain, aggregation by physical activity. (bilateral)
At least one of: nausea/vomiting, photophobia, phonophobia. (Can be inferred)
Not attributed to another disorder.
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In practice
Recurrent headache that bothers
Nausea with headache
Light bothers
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Implications for gastric stasis and neck pain
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MigraineAcute treatment
Paracetamol, Aspirin, Domperidone.
Triptan
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Triptans
Sumatriptan 100mg Sumatriptan 50mg Rizatriptan 10mg Zolmitriptan 2.5mg Eletriptan 20mg/40mg
Almotriptan 12.5mg
Naratriptan 2.5mg Frovatriptan
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Triptan Half Life
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Triptans – some practical points
Treat early Failure not class effect Not in CVD SSRIs Over 65 years
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CASE 7b
Jane’s headaches become more frequent. When would you instigate prevention?
What is your first choice?
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Migraine treatmentPreventative
When to instigate?
What to use?
How long for to assess an effect?
What rate dose increase?
How long on preventative medication?
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• Beta blocker ++ (L)• Pizotifen + - (L)• Amitriptyline +• Gabapentin +• Sodium valproate + +• Topiramate +++ (L)• Calcium antagonists + -• Lisinopril, Montelukast + -• Clonidine - - -• Methylsergide ++(L)
Migraine prevention +- evidence and licence
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CASE 7c
Jane has come for contraceptive advice.
What options does she have?
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What about the pill?Ischaemic stroke
Fit women - 5/100,000 women years
Without aura - 15/100,000 women years
With aura - 30/100,000 women years
Avoid if other risk factors Eg smoking
?POP - probably safe
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CASE 7d
After a few years, the migraines have settled to monthly and associated with menstruation only. She is fed up with taking regular prevention.
How will you manage this?
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Oestrogen sensitive migraine
Menstrual (pure - 7%, and other times
35%)
Peri-menopausal
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Menstrual Migraine
Tricycle OC
Regular NSAI
100 mcg oestrogen patch
Regular long acting Triptan
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Peri-menopausal migraine
Too much oestrogen too quickly - worse
25 mcg Evoral patch in quarters
Avoid oral oestrogen
Reassure will get better
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CASE 8
Jane brings in her 13 year old son who is getting trouble with headache. In view of the family history you suspect migraine.
How do features in children differ from adults?
Would you image? What treatment would you instigate?
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HeadacheA complex biopsychosocial interaction
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Primary Headache Epidemiology
Headache most frequent neurological problem in children and commonest manifestation of pain
50% Childhood migraine becomes chronic and continues into adulthood
<10% will see their GP
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Primary Headache Epidemiology
10.6% migraine prevalence (3.4% age 5)
10% -24% tension type prevalence
0.01% cluster prevalence
Invariably mixed or not well defined
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Why don’t children seek help?
Mortimer 1992
Don’t realise its migraine
Only a headache
Parents don’t want to reinforce illness behaviour
Parents pattern their health seeking behaviour
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What is happening in primary care?
GPs made diagnosis in 20%
25% referred to secondary care
3 in 10,000 tumour
No tumours if migraine diagnosed
Kernick Cephalalgia 2009
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Diagnosis Total in cases
Total in controls
LR (confidence intervals)
Depression 1.5% 0.67% 2.2
(1.9,2.5)
Depression in year after headache presentation
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Problems with Children under 3 years
Unable to articulate symptoms of raised intracranial pressure
Problem may be suggested by their behaviour in ways that may be relatively subtle
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Features childhood migraine
Pain is shorter acting More likely to be bilateral Often “mixed” Associated with other systemic
presentations
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Presentation of Brain Tumour 40% headache (<10% headache alone)
28% nausea and vomiting
22% motor abnormalities
17% visual abnormalities
17% cranial nerve abnormalities
10% seizures
3% behavioural change
Wilme 2010
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Red Flags Discuss with Paediatrician the same day
Abnormal neurological sign Confusion or disorientation Visual abnormalities Abnormal head position (double vision or neck pain) Cerebella dysfunction Persistent headache for 4 or more weeks at presentation that
awake from sleep or occur on waking Persistent headache at any time in a child younger than 4 years Persistent headache for 2 or more weeks with vomiting
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Orange Flag presentationsNeed referral/close monitoring
Headache with behavioural change Headache with deterioration in school work Headache with growth arrest or abnormal
puberty A persistent unilateral or occipital headache A persistent headache in a child with a
personal or family history of childhood tumour Recent change in headache characteristics in a
previous diagnosed primary headache
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Management
Avoidence of triggers Analgesia +-Domperidone Sumatriptan nasal
Pizotifen Propranolol Amitrip Topiramate
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School Policy Guidelines. RCGP, Headache UK, RCN
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Diagnosing the right headacheThree Key Questions
1 - What is the impact?
Migraine - lie down Tension Type Headache - keep going Cluster Headache - bang head against wall
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Diagnosing the right headacheThree Key Questions
2 - How many types of headache do you recognise?
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Diagnosing the right headacheThree Key Questions
3 - What pain killers are you taking?
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