Steve ElliotGPwSI Headache

Diagnosis of episodic headacheDiagnosis of chronic headacheWho to refer for scanning(Management of headache)

“Listen to the patient. He is telling you the diagnosis”

Sir William Osler (1849-1919)

“The headache history has to be taken, not received”

Professor Peter Goadsby

Why does it matter?Headache is not a diagnosisClear diagnostic criteriaDiagnosis before treatmentDisease specific treatments

Guatama Buddha 563-483 BCHow to relieve suffering

8 questions - the way to end suffering in headacheLocation?Character?Severity?Aggravation by movement?Nausea/vomiting?Photophobia?Phonophobia?Duration?

IHS tension headache2 ofBilateralPressing./tightening/non pulsating qualityMild to moderate intensityNot aggravated by movementNo more than 1 ofNausea/vomitingPhonphobia or photophobiaDuration 30minutes to 7days

IHS migraineNeed 2 out of:UnilateralModerate-severeThrobbingWorse with movementNeed 1 ofNausea and/or vomitingPhotophobia and phonophobiaDuration 4-72 hours

Cluster headacheSide locked unilateralPeircing /drilling/grindingVery severeNot worse with movementPossibly nausea/vomitingPossibly unilateral photophobiaPossible phonophobia15-180 minutes durationAutonomic symptomsRestless

Landmark study1203 patientsGP diagnosis of primary headacheHeadache diary for 3monthsDiaries analysed by blinded assessorsFindings:94% migraine or probable migraine82% “tension type headache” had migraine

Agree or disagree?

“ ... She complains of frequent headaches and she has missed a lot of time off work. She is having to look after her demented mother and is under considerable stress. The headaches are throbbing and associated with nausea and occasional vomiting. She has been to A+E on two occasions. Neurological examination is normal. I feel she is suffering from chronic tension headache.”

“Brain attack”Trigger – Dorsal ponsProdrome - HypothalmusAura – Cerebral cortexPeripheral sensitisation – Cranial vasculatureCentral sensitisation – ThalamusNausea/vomiting- Area Postrema Autonomic symptoms – Parasympathetic

systemNeck pain – Sensitisation of C2/C3

Why me?Blame your parentsChemical imbalanceYour brain is differentSymptoms between attacks

Chronic headache2-3% of population have headache on

more days than don’tHalf of above have medication overuse2%/year migraine transforms to chronicMost preceded by episodic headacheCo-mordidities anxiety,depression,obesityDifficult to manage

Causes chronic daily headachePrimary headachesChronic tension type headacheChronic migraineChronic cluster headacheMedication overuse headacheNew daily persistent headacheHemicrania continua

History in chronic headachePattern

Low grade all time?Low grade with exacerbations?Short lasting frequent?

Stable or progressive?8 questionsMedication including OTC?Caffeine consumption?Exclude red flags

What not to missIdiopathic intracranial hypertensionLow pressure headache Giant cell arteritisOther secondary headache

REMEMBERHigh pressure headache WORSE on lying flatLow pressure headache BETTER lying flat

Neuroimaging guidelines- a brief summary

What do we know?Incidence of brain tumour in general

population is 0.06-0.01% per year72% occur over age 50In primary care risk of brain tumour with

headache presentation is 0.09%If GP makes diagnosis of primary headache

risk is 0.045%If GP cannot make diagnosis then risk is

0.15% and 0.28% if >50

What else do we know?Risk of brain tumour >1% ifPapilloedemaNew epileptic seizureSignificant alteration consciousness, memory

loss ,co-ordination, confusionHistory of cancer elsewhere

Risk of lung cancer with haemoptysis 2.4%Risk of colon cancer with positive FOB 7%

SIGN guidelines“Neuroimaging is not indicated in patients with a clear history of migraine,without red features for potential secondary headache,and a normal neurological examination”

NICE, TWW and headacheHeadaches in whom a brain tumour is suspectedHeadache of recent onset accompanied by

features suggestive of raised intracranial pressure egVomitingDrowsinessPosture related headachePulse synchronous tinnitusOr by other focal or non-focal neurological symptoms

eg blackout,change in memory or personalityNew, qualitatively different,unexplained

headache that becomes progressively severe

Brain tumour headache55% new or changed headache5.1% “classic” raised ICP features 55.1% not classifiable by IHS13.3% migraine23.5% episodic tension type headache40.8% occurred on 1-3 days per week60.2% “pressing/tightening”52% no trigger

And...3-8% headache as only symptom74% brain tumours present within 3months90% within 6 monthsBrain tumour headache may be similar to

previous headache but more frequent/severe and associated with new symptoms

Red flags-SIGN guidelinesNew onset or change in

patient over 50New onset headache with

history of cancerAbnormal neurological

examinationHeadache that changes

with postureHeadache that wakes

(most common migraine)Headache precipitated by

physical exertion/ValsalvaNon focal neurological

symptoms eg cognitive disturbance)

Patients with risk factors for CVST

Jaw claudication or visual disturbance

Neck stiffnessFeverChange in headache

frequency,characteristics or associated symptoms

Thunderclap headacheHeadache that changes with

postureNew onset in patient with

HIVFocal symptoms <5min or

>60Thunderclap heaadche

ParacetamolAspirin or IbuprofenAnti-emetic Domperidone or MetoclopramideNaproxen or DiclofenacTriptanCombinationAVOID OPIOIDS

Acute treatment migraine

AlmotriptanEletriptanFrovatriptanNaratriptanRizatriptanSumatriptanZolmitriptan

Which Triptan?

2 hour responseChance of relapseAdverse effectsCostRoute of administration

Which Triptan?

Tension type headacheAmitriptyline/Nortriptyline(Mirtazapine)MigraineAmitriptyline/NortriptylinePropranolol/MetoprololTopiramate Sodium valproate or Gabapentin

Prophylaxis of headache

“ The very first step towards success in any occupation is to become interested in it”

Sir William Osler (1849-1919)Canadian Physician