richard sylvester consultant neurologist homerton university hospital / nhnn
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Richard SylvesterConsultant Neurologist Homerton University Hospital / NHNN
Vast majority requests are MRI for headache
Where does MRI fit in the management of headache?
What headaches present?
Managing headache – pearls and pitfalls
Developing an integrated pathway for headache
Correct diagnosis – history/examination
Effective management – knowledge
Tests valuable only in minority of cases
Homerton neurology OPD (Oct – Dec 2012)
94/352 (27%) patients main complaint headache96% primary (78% migraine, 13% TTH, 9% other)45% analgesia overuse1/3 previous imaging1/3 imaged after clinic85% discharged
>90% migraine>65% analgesia overuse
When GP diagnosis is migraine – correct 98%If GP diagnosis is not migraine – incorrect 82%
(Tepper et al, Headache 2004)
Recurrent attacks
Headache lasting 4–72 hours untreated
At least two symptoms of:Throbbing/pulsatingUnilateralModerate or severeWorsened by movement/avoids routine physical activity
And either:Nausea +/or vomitingPhotophobia or phonophobia
ICHD-2, 2004
Lifestyle – regular sleep, food/drink, reduce stress
Abortive – high dose NSAID/domperidone - triptan/domperidone
Prophylactic – propanalol, AEDs, amitriptylline
Education – migraine trust website
(Imaging – <1:2200 brain tumour)
UnderdiagnosisLack of all migrainous symptomsAbsence of aura (>80%)Chronic headache – analgesia overuse
UndermanagedAnalgesia overuse propagatedAbortives not used correctlyProphylactics - dose / length of treatment
NMC guidance for GPs
>14 days month
>2 days analgesic use per week
Any analgesic
Underlying primary headache
Reduces efficacy of prophylactics
Addiction pathway?
Primary TTH – featureless, no analgesia overuseCluster – 1-3 hrs, agitatedTACS – rare
Secondary‘Red flags’
Diagnose/exclude serious pathology
Relieve anxiety (patient / doctor)
Avoid referral to specialist (cost)
Patient choice
It excludes serious pathology
But headache alone is not a marker of structural pathology
‘red flag’ features are – need specialist input/imaging
Thunderclap headache (peak intensity 1-5mins lasting >1hr)Fever/systemic illness Focal neurology / seizuresCognitive declineNew onset daily headache in high risk group(>50yrs/cancer/immunosuppressed)Postural features suggestive low / high CSF pressure
It relieves anxiety
Maybe in the short term but not for longRCT imaging vs noneOutcome measure – anxiety scores / Is my headache caused by
something serious ?Less anxiety at 3 months but not at one year (Howard et al JNNP 2005)
Around 5% are not normal – more anxietyChiari malformationsArachnoid/Pineal cystsSmall meningiomas/aneurysmsWhite matter lesionsPituatary abnormalities
Avoids specialist referral and reduces costs
No cost benefit – minor reduction in referral rate(Wills et al, JNNP 2005)Open Access MRI with GP referral guidelines 169 scans in 12 monthsIncidentaloma rate: 3% No reduction in costs and minor reduction in referrals
Imaging doesn’t diagnose and manage symptoms
Patients want scans
Yes but they would prefer to get rid of their symptoms
Normal scan may lead to trivialising symptoms
Red flags
Triggered headache
Head injury
NODPH
Rare phenotypes
When I have little choice!
CT
short wait, good for fractures / large lesions / less incidentalomas but radiation, poor resolution
MRI – often need specific sequences
Trauma – GE/SWI?low CSF pressure – contrast TACS – pituitary imagingTN – brainstem sequencesMRA/MRV – arterial/venous pathology
Urgent - Neurology SPR Homerton / RLH
Routine - Email advice [email protected]
Red flags?Yes
Urgent? A&E / medics / neuro SPRYes
No Neurology OP Email advice service
No
Analgesia overuse?Yes Stop analgesics
success?No
?psychiatry input
Diagnostic pattern?
Yes
Headache diaryReview in 8/52 Diagnosis?
No
No
Neurology OP Email advice service
Migraine?Yes
Yes
No
Yes
TreatmentTriggersAbortiveProphylaxis
Neurology OP Email advice serviceNo
Primary care management e.g. TTH, musculoskeletal
No
Others – cluster, TACSTriggered, NODPH
Imaging
Imaging
Imaging
Always consider the aims and likely outcomes of brain imaging
There are limited indications for brain imaging in headache
Correct diagnosis and management are morereassuring than normal tests
Its usually migraine and analgesia overuse!
Migraine trusthttp://www.migrainetrust.org/
National migraine centrehttp://www.migraineclinic.org.uk/
BASHhttp://www.bash.org.uk/