HeadacheDr Gina KennedyConsultant in NeurologySunderland Royal Hospital

29 million headache-suffering days in UK annually

• 30% Neurology OPD• 100,000 people off

school/work/day• Huge socioeconomic

burden

Aims: Today we need to …

• Review primary headache diagnosis(ICHD II)• Practical management (NICE)• Headaches not to miss: when to refer/ to scan

or not to scan• Leave without a headache

Adult with Headache

Emergency symptoms?1 Refer to appropriate on-call hospital team

Red flags?3

Use Advice & Guidance Service or refer general neurology

Can you make a diagnosis of primary headache disorder?

Prescribe acute treatment (< 10 days/month)4

Refer to headache clinic

Inadequate response to migraine preventatives. Is it

chronic daily headache (>15/7 per month)?

Use headache diary

Migraine or tension headache4

?

Giant cell arteritis?2

• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura• Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect

from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger

avoidance, stress management techniques, normalise BMI, daily aerobic exercise)Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:

teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.

c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture

Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse.

Cluster headache?5

Try acute treatments5

Check ESR and CRPPrednisolone 60mg o.d. immediately

Consider urgent referral to rheumatology as appropriate2

(Need temporal artery biopsy within 2 weeks of starting prednisolone)

Yes

Yes

No

No

No

No

Yes

Northern East Headache Management GuidelineNovember 2015

Refer urgently to Neurology

Yes

Yes

Consider CT brain pre-referral

1)

3)

Migraine (don’t need a full house!)• Throbbing pain lasting hours - 3 days• Sensitivity to stimuli: light and sound, sometimes smells• Nausea• Aggravated by physical activity (prefers to lie/sit still)Aura (if present):-

• evolves slowly (in contrast to TIA/stroke)• lasts minutes - 60min

‘Chronic Migraine’≥15 headache days/month of which ≥8 are migraineAcute treatments:Aspirin disp. 900mg or NSAID, taken with prochlorperazineA triptan, but no more than 9 days per month (best <6/month)Don’t use opiates as they tend to lead to increase nausea and lead to an overuse headachePoor absorption common in a headache attack – therefore better efficacy with anti-emetic, or non-oral (e.g. diclofenac supp, s/c or nasal triptan)

Tension Type HeadacheBand-like acheMostly featurelessCan have mild photo OR phonophobia but NO nauseaMany believe this is simply a milder form of migraine (i.e. samebiology and thus similar treatments can be effective)

Cluster Headache (Mostly men)Most severe pain ever lasting 30-120 minutesUnilateral, side-lockedAgitation, pacing (cf migraineurs prefer to keep still)Unilateral Cranial Autonomic features:-

tearing, red conjunctiva, ptosis, miosis, nasal stuffiness

Acute treatments: Sumatriptan injection 6mg s.c. (Contraind.: IHD and stroke)Hi-flow oxygen through a non-rebreathe bag and mask (10-12litres/min)Prednisolone 60mg o.d. for 1 week can abort a bout of attacks

2)

Analgesic/Triptan Overuse HeadacheOften mixture migraine and background headacheAnalgesic intake ≥15 days/month (opiates/triptans ≥10 days) for ≥3 consecutive monthsTreatment: stop analgesic and triptan for 2 months and follow up

Red Flags• Headache rapidly increasing in severity and frequency despite appropriate treatment.

• Undifferentiated headache (not migraine / tension headache) or new persistent daily headache of recent origin and present for >8 weeks with focal neurological signs or high clinical suspicion of underlying structural cause.

• Recurrent headaches triggered by exertion• New onset headache in:-

>50 years old (consider giant cell arteritis)Patients with focal neurological signs or change in personalityImmunosuppressed / HIV

4)Emergency Symptoms/signsThunderclap onset (i.e. max intensity in <5 mins)Accelerated/Malignant hypertensionAcute onset with papilloedemaAcute onset with focal neurological signsHead trauma with raised ICP headachePhotophobia + nuchal rigidity + fever +/-rashReduced consciousnessAcute red eye: ?acute angle closure glaucomaNew onset headache in:

• 3rd trimester pregnancy/early postpartum• Significant head injury

(esp. elderly/ alcoholics / on anticoagulants)

Giant Cell arteritis (Incidence 2/10,000/ year)• Think about it: New headache in >50 year old• Other headaches may briefly respond to high dose steroids, so do not use response as the sole diagnostic factor.• ESR can be normal in 10% (check CRP as well)• Symptoms of classical GCA can include: jaw/tongue claudication, visual disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudicationUrgent referral: rheumatology if GCA diagnosis suspected, ophthalmology or TIA clinic if amaurosis fugax / visual loss / diplopia (not migrainous auras!).

Patient in GP setting: Who to scan ?Basically, no-one who does not needreferring in needs a scan. However, ifa scan is being done for reassurance, aCT head scan will suffice.

5)

6)

Headache Clinic• History:

– PMH : ‘headachy person?’, lifestyle changes– short or long lasting headache? 4 hours– description of severe attack and frequency– associated symptoms– functionally limiting?– number of HEADACHE-FREE days/month

• Examination:– Fundoscopy, visual fields, palpation of temporal arteries, TMJ, neck muscles,

cervical spine• Headache Impact Test Score >60 severe• Use of diaries to record headaches, associated symptoms and

medication use- identify patterns

Primary Headache

Headache with any of:Nausea/photo/phonophobia

Throbbing/Unilateral/Movement

Aura?Visual/sensory/

speech

Migraine with aura

Migraine without aura

Menstrual Migraine

Medication over use

excluded?*

Tension Type Headache

Medication overuse headache

<15 days/month:Episodic

>15 days/month:Chronic

Yes

Yes

Yes No

No

No

* Use of triptans/opioids > 10 days/month, paracetamol/NSAIDS>15 days/month

Case 1• 34 year old female 4 year history of

mainly right sided headache approximately twice a month which radiate over rest of head lasting 2-3 days

• No nausea but ‘off food’ with no photophobia, phonophobia, worse with playing netball

• Typically feels hungry and lethargic with recurrent yawning in days leading up to headache

A. Migraine without auraB. Migraine with auraC. Chronic migraineD. Tension-type H/AE. Trigeminal autonomic

cephalalgiaF. Medication overuse

headacheG. Other

Case 1• 34 year old female 4 year history of

mainly right sided headache approximately twice a month which radiate over rest of head lasting 2-3 days

• No nausea but ‘off food’ with no photophobia, phonophobia, worse with playing netball

• Typically feels hungry and lethargic with recurrent yawning in days leading up to headache

A. Migraine without auraB. Migraine with auraC. Chronic migraineD. Tension-type H/AE. Trigeminal autonomic

cephalalgiaF. Medication overuse

headacheG. Other

Migraine without Aura

Migraine with aura

• 20% migraine patients• Focal reversible neurological disturbance• Onset 5-20 minutes, 5-60 minutes duration• At least one of: Visual > sensory > dysphasia• No motor weakness• Refer if atypical (no headache, motor

weakness, monocular visual symptoms, altered GCS)

• Differential TIA: sudden, negative

Migraine: misdiagnosis

• 50% misdiagnosed• 4-72 hours: can be longer• 75% neck pain• 1/3 nausea and vomiting• Chronic: headache 15 days/month, only 8/30

days a month with migraine features

Migraine: acute treatment• 1. LIFESTYLE

– Stress/ sleep/ diet/ caffeine

• 2. simple oral analgesia +/- antiemetic– Aspirin 600-900mg/ ibuprofen

400-600mg soluble – Prochlorperazine 3-6mg buccal

tablet/ domperidone 10mg– Migraleve/Paramax

• 3. Rectal preparations– Diclofenac suppositories 100mg– Domperidone suppositories 30-

60mg

• 4. Triptans– Oral sumatriptan– Nasal spray sumatriptan/

zolmitriptan– Sublingual zolmitriptan/ rizatriptan– Subcutaneous sumatriptan

• 5. Combination therapy– Sumatriptan + naproxen

• 6. Emergency treatment– Sumatriptan 6mg s.c.– Diclofenac 75mg i.m.– Chlorpromazine 25-50mg/

metaclopramide 10mg/ prochlorperazine 12.5mg

Migraine Prophylaxix

• Affecting QOL: consider anything over 1 x migraine/month

• Titrate slowly and complete at least 6-8 weeks• Reach highest tolerable/ effective dose• Review 3-6 monthly

Migraine Prophylaxis

• Class C:– Candesartan 8-32mg od– Lisinopril

• Less:– Gabapentin/ pregabalin– Verapamil

• Class A: – Topiramate 25-50mg bd– Sodium valproate 600-

1200mg bd• Class B:

– Propanolol 80-240/day– Amitriptyline 30-150mg– Nortiptyline 25-100mg– Atenolol 25-50mg bd– Feverfew– Riboflavin B2 400mg /day

Migraine in women

• Menstual migraine: Naproxen 250-500mg bd, Frovotriptan 2.5mg-5mg bd, Tricyclic OCP, oestrogen patches (100 micrograms for 3/7)

• Pregnancy: Paracetamol, Propanolol, Prochlorperazine, Amitripyline, triptans

• CVA risk: migraine without aura (1.83 RR), migraine with aura (2.17 RR)+ COCP + smoker = 9 x CVA risk

Chronic migraine

• Headache fulfilling diagnostic criteria for migraine without aura

• for at least 15 days/month for 3 months• Only 8 of which have migrainous features• In absence of medication overuse

Botulinum Toxin

• Technology Appraisal TA 260• Chronic migraine• 3 x failed preventatives• Medication overuse addressed• BoTox discontinued if <30% improvement or <15

days/month (episodic)• PREEMPT study: reduced headache days (8-9/month

cf placebo 6/month), well tolerated• 155 units in 31 sites

What the patient’s say..

• “I feel like I can be a mother to my children again”• “I don’t feel I am overstating things to say it has

changed my life!”• “My family have noticed the benefit, I am spending

more time out of my bedroom”• “My wife now wakes up smiling”• “Remarkable”• “I have been able to stop topiramate and start

planning a family”

Case 2

Case 2

• Migraine without aura• Migraine with aura• Chronic migraine• Tension-type H/A• Trigeminal autonomic cephalalgia• Medication overuse H/A• Other

Case 2

• Migraine without aura• Migraine with aura• Chronic migraine• Tension-type H/A• Trigeminal autonomic cephalalgia• Medication overuse H/A• Other

Medication Overuse Headache• Headache diary!

• Triptan, opioid, ergot >10 days month• Paracetamol, aspirin, NSAID >15 days/month

Management MOH

• Stop overused medication• Consider starting a prophylaxis in patients with

migraine (amitriptyline, beta-blocker, valproate)• Naproxen 250-500mg bd for 6/52• Warning: things get worse before getting better,

aim to review regularly, should start to see benefit at 1 month

• Review diagnosis at 2 months

Medication overuse outcome

Case 3• Migraine without aura• Migraine with aura• Chronic migraine• Tension-type H/A• Trigeminal autonomic

cephalalgia• Medication overuse H/A• Other

• 42 year old man, 3/12 moderate constant generalised headache with tender areas

• No nausea• Not worse with moving,

position or Valsalva• Can continue daily

activities

Case 3

• Migraine without aura• Migraine with aura• Chronic migraine• Tension-type H/A• Trigeminal autonomic

cephalalgia• Medication overuse

H/A• Other

• Bilateral pressing/tightening quality, with or without pericranial tenderness (on manual palpation)

• 30 minutes-7days• Not worsened by physical

activity• No nausea, occasional mild

photophobia/phonophobia• Associated with depression/

anxiety• Temporomandibular joint

dysfunction, referred neck pain (cervicogenic)

Tension type headache: treatment• Bilateral featureless ‘tight’ constant headache• Acute treatment: NSAIDS, aspirin, paracetamol• Amitriptyline, duloxetine, dosulepin, mirtazepine• Relaxation/massage/heat/exercise• Acupuncture: 10 sessions over 5-8 weeks

Case 4: Video

3. Trigeminal Autonomic Cephalalgias

• Headache with activation of trigeminal parasympathetic reflex (conjunctival injection and lacrimation, rhinorrhoea, miosis, ptosis (Horner’s), facial sweat, agitation)

• Cluster headaches: episodic (15-180 mins up to 8x/day for several weeks) / chronic (> one year with remission periods less than 1 month)

• Paroxysmal hemicrania (2-30 mins 40x/day) Indomethacin-sensitive!

• SUNCT (short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing) (5 secs-4mins 30x/hour)

Cluster Headache• Men, 30’s, smokers• Unilateral excrutiating pain over one eye for

1-3 hours, same time each day, commonly at night (REM sleep as trigger)

• Agitated• Bouts for 6-12 weeks, 1-2 X per year• Worse with ETOH• Differential: Hypnic headache (ask about

sleep apnoea, nocturnal hypertension)

Treatment: Cluster headache• Stop smoking/ETOH• Sumatriptan 6mg subcut./nasal spray• High flow 100% oxygen 10-15L/min • Intranasal lignocaine 2%• 1mg/kg prednisolone for 2/52, reduce by 10mg/day• Verapamil 80mg tds-320mg tds, check ECG at every

increment• Methysergide 1-12mg• Lithium 200 bd- 800 bd• Topiramate/gabapentin/melatonin

Adult with Headache

Emergency symptoms?1 Refer to appropriate on-call hospital team

Red flags?3

Use Advice & Guidance Service or refer general neurology

Can you make a diagnosis of primary headache disorder?

Prescribe acute treatment (< 10 days/month)4

Refer to headache clinic

Inadequate response to migraine preventatives. Is it

chronic daily headache (>15/7 per month)?

Use headache diary

Migraine or tension headache4

?

Giant cell arteritis?2

• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura• Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect

from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger

avoidance, stress management techniques, normalise BMI, daily aerobic exercise)Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:

teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.

c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture

Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse.

Cluster headache?5

Try acute treatments5

Check ESR and CRPPrednisolone 60mg o.d. immediately

Consider urgent referral to rheumatology as appropriate2

(Need temporal artery biopsy within 2 weeks of starting prednisolone)

Yes

Yes

No

No

No

No

Yes

Northern East Headache Management GuidelineNovember 2015

Refer urgently to Neurology

Yes

Yes

Consider CT brain pre-referral

When is it an emergency?• Emergency Symptoms/signs• Thunderclap onset (i.e. max intensity in <5 mins)• Accelerated/Malignant hypertension• Acute onset with papilloedema• Acute onset with focal neurological signs• Head trauma with raised ICP headache• Photophobia + nuchal rigidity + fever +/-rash• Reduced consciousness• Acute red eye: ?acute angle closure glaucoma• New onset headache in:

•3rd trimester pregnancy/early postpartum•Significant head injury–(esp. elderly/ alcoholics / on anticoagulants)

Adult with Headache

Emergency symptoms?1 Refer to appropriate on-call hospital team

Red flags?3

Use Advice & Guidance Service or refer general neurology

Can you make a diagnosis of primary headache disorder?

Prescribe acute treatment (< 10 days/month)4

Refer to headache clinic

Inadequate response to migraine preventatives. Is it

chronic daily headache (>15/7 per month)?

Use headache diary

Migraine or tension headache4

?

Giant cell arteritis?2

• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura• Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect

from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger

avoidance, stress management techniques, normalise BMI, daily aerobic exercise)Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:

teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.

c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture

Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse.

Cluster headache?5

Try acute treatments5

Check ESR and CRPPrednisolone 60mg o.d. immediately

Consider urgent referral to rheumatology as appropriate2

(Need temporal artery biopsy within 2 weeks of starting prednisolone)

Yes

Yes

No

No

No

No

Yes

Northern East Headache Management GuidelineNovember 2015

Refer urgently to Neurology

Yes

Yes

Consider CT brain pre-referral

When is it GCA?• Giant Cell arteritis (Incidence 2/10,000/ year)•Think about it: New headache in >50 year old•Other headaches may briefly respond to high dose steroids, so do not use

response as the sole diagnostic factor.•ESR can be normal in 10% (check CRP as well)•Symptoms of classical GCA can include: jaw/tongue claudication, visual

disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudication• Urgent referral: rheumatology if GCA diagnosis suspected, ophthalmology

or TIA clinic if amaurosis fugax / visual loss / diplopia (not migrainous auras!).

Adult with Headache

Emergency symptoms?1 Refer to appropriate on-call hospital team

Red flags?3

Use Advice & Guidance Service or refer general neurology

Can you make a diagnosis of primary headache disorder?

Prescribe acute treatment (< 10 days/month)4

Refer to headache clinic

Inadequate response to migraine preventatives. Is it

chronic daily headache (>15/7 per month)?

Use headache diary

Migraine or tension headache4

?

Giant cell arteritis?2

• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura• Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect

from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger

avoidance, stress management techniques, normalise BMI, daily aerobic exercise)Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:

teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.

c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture

Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse.

Cluster headache?5

Try acute treatments5

Check ESR and CRPPrednisolone 60mg o.d. immediately

Consider urgent referral to rheumatology as appropriate2

(Need temporal artery biopsy within 2 weeks of starting prednisolone)

Yes

Yes

No

No

No

No

Yes

Northern East Headache Management GuidelineNovember 2015

Refer urgently to Neurology

Yes

Yes

Consider CT brain pre-referral

When to scan?•Red Flags•Headache rapidly increasing in severity and frequency despite appropriate treatment.

•Undifferentiated headache (not migraine / tension headache) or new persistent daily headache of recent origin and present for >8 weeks with focal neurological signs or high clinical suspicion of underlying structural cause.

•Recurrent headaches triggered by exertion•New onset headache in:- >50 years old (consider giant cell arteritis) Patients with focal neurological signs or change in personality Immunosuppressed / HIV

Patient in GP setting: Who to scan ?Basically, no-one who does not need referring in needs a scan. However, if a scan is being done for reassurance, a CT head scan will suffice.

What to refer

• High suspicion secondary cause• Complicated headache type for diagnosis• Headache refractory to treatment

• BEFORE referral: – Optimise rescue treatment– Review medication overuse– Try prophylactics x 3

Summary• Headaches are common• Diagnosis and appropriate treatment/referral of

primary headaches• Identify symptoms/signs of serious causes and triage

according to pathway• Hopefully now leave without a headache!

Useful Information

• www.ihs-headache.org• www.bash.org.uk• www.ouchuk.org• www.exeterheadacheclinic.org.ukFor patients:• National Migraine Centre:

www.nationalmigrainecentre.org.uk• www.migrainetrust.org.uk

Adult with Headache

Emergency symptoms?1 Refer to appropriate on-call hospital team

Red flags?3

Use Advice & Guidance Service or refer general neurology

Can you make a diagnosis of primary headache disorder?

Prescribe acute treatment (< 10 days/month)4

Refer to headache clinic

Inadequate response to migraine preventatives. Is it

chronic daily headache (>15/7 per month)?

Use headache diary

Migraine or tension headache4

?

Giant cell arteritis?2

• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura• Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect

from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger

avoidance, stress management techniques, normalise BMI, daily aerobic exercise)Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:

teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.

c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture

Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse.

Cluster headache?5

Try acute treatments5

Check ESR and CRPPrednisolone 60mg o.d. immediately

Consider urgent referral to rheumatology as appropriate2

(Need temporal artery biopsy within 2 weeks of starting prednisolone)

Yes

Yes

No

No

No

No

Yes

Northern East Headache Management GuidelineNovember 2015

Refer urgently to Neurology

Yes

Yes

Consider CT brain pre-referral

1)

3)

Migraine (don’t need a full house!)• Throbbing pain lasting hours - 3 days• Sensitivity to stimuli: light and sound, sometimes smells• Nausea• Aggravated by physical activity (prefers to lie/sit still)Aura (if present):-

• evolves slowly (in contrast to TIA/stroke)• lasts minutes - 60min

‘Chronic Migraine’≥15 headache days/month of which ≥8 are migraineAcute treatments:Aspirin disp. 900mg or NSAID, taken with prochlorperazineA triptan, but no more than 9 days per month (best <6/month)Don’t use opiates as they tend to lead to increase nausea and lead to an overuse headachePoor absorption common in a headache attack – therefore better efficacy with anti-emetic, or non-oral (e.g. diclofenac supp, s/c or nasal triptan)

Tension Type HeadacheBand-like acheMostly featurelessCan have mild photo OR phonophobia but NO nauseaMany believe this is simply a milder form of migraine (i.e. samebiology and thus similar treatments can be effective)

Cluster Headache (Mostly men)Most severe pain ever lasting 30-120 minutesUnilateral, side-lockedAgitation, pacing (cf migraineurs prefer to keep still)Unilateral Cranial Autonomic features:-

tearing, red conjunctiva, ptosis, miosis, nasal stuffiness

Acute treatments: Sumatriptan injection 6mg s.c. (Contraind.: IHD and stroke)Hi-flow oxygen through a non-rebreathe bag and mask (10-12litres/min)Prednisolone 60mg o.d. for 1 week can abort a bout of attacks

2)

Analgesic/Triptan Overuse HeadacheOften mixture migraine and background headacheAnalgesic intake ≥15 days/month (opiates/triptans ≥10 days) for ≥3 consecutive monthsTreatment: stop analgesic and triptan for 2 months and follow up

Red Flags• Headache rapidly increasing in severity and frequency despite appropriate treatment.

• Undifferentiated headache (not migraine / tension headache) or new persistent daily headache of recent origin and present for >8 weeks with focal neurological signs or high clinical suspicion of underlying structural cause.

• Recurrent headaches triggered by exertion• New onset headache in:-

>50 years old (consider giant cell arteritis)Patients with focal neurological signs or change in personalityImmunosuppressed / HIV

4)Emergency Symptoms/signsThunderclap onset (i.e. max intensity in <5 mins)Accelerated/Malignant hypertensionAcute onset with papilloedemaAcute onset with focal neurological signsHead trauma with raised ICP headachePhotophobia + nuchal rigidity + fever +/-rashReduced consciousnessAcute red eye: ?acute angle closure glaucomaNew onset headache in:

• 3rd trimester pregnancy/early postpartum• Significant head injury

(esp. elderly/ alcoholics / on anticoagulants)

Giant Cell arteritis (Incidence 2/10,000/ year)• Think about it: New headache in >50 year old• Other headaches may briefly respond to high dose steroids, so do not use response as the sole diagnostic factor.• ESR can be normal in 10% (check CRP as well)• Symptoms of classical GCA can include: jaw/tongue claudication, visual disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudicationUrgent referral: rheumatology if GCA diagnosis suspected, ophthalmology or TIA clinic if amaurosis fugax / visual loss / diplopia (not migrainous auras!).

Patient in GP setting: Who to scan ?Basically, no-one who does not needreferring in needs a scan. However, ifa scan is being done for reassurance, aCT head scan will suffice.

5)

6)