I’ve got a headach

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HeadacheDavid KernickExeter Headache Clinic

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

When people come to see you what do they think they have?

When people come to see you what do they think they have?

Need glasses

Blood pressure

Brain tumour

What do patients have when they present to GP with

headache?

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

What do GPs think when patients present with headache? (Kernick 2008)

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Pe

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20 40 60 80 100Age

Cluster MigraineTension Secondary

Undifferentiated

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.

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

Headache referral patterns

9% GP presentations are referred to secondary care (25% children)

(Loughey)

20 - 30% of neurology referrals are for headache

(Hopkins)

What do patients have when they present to A and E with

headache? Valade 2000

n – 9480

Average age 37

250 admitted (3%)

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%

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?

Classifying headache

Where does the pain come from?Intra – cranial (dural pain fibres)

Tension – raised intracranial pressure

Compression – tumour

Inflammation - migraine,meningitis,blood

Where does the pain come from?Extra - cranial

Arteritis Neuralgia Muscle tension Facial structures

IHS Headache classification Primary Secondary

Migraine Tension type Autonomic cephalalgias

(cluster)

Traumatic Vascular Non-vascular (SOL) Substance induced Infection Disturbed homoestasis Facial structures

Activation anywhere in the system can lead to output in any other part of the system and vici versa

Thalamus +Mid Brain structures

Medication overuse headache

Tension type headache

AURA

CERVICALNUCLEI

MIGRAINECENTRE

HypothalamusCLUSTER

Headache model

Secondary Headaches

Primary Headaches

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?

Two examinations

Fundoscopy

BP

Giles Elrington neurological examination

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?

Headache Pathway

EXCLUDE A SECONDARY HEADACHE Do something now Do something soon

DIAGNOSE A PRIMARY HEADACHE Exclude medication overuse and manage the

primary headache

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?

Sub Arachnoid - thunderclap headache

Thunderclap headache - RVS

lasts 1-3 mths.

Primary or secondary

Normal CT, LP. Needs CT angio.

Can get complications

Meningitis

Malignant hypertension

Migraine - The emergency call out

Injectable sumatriptan

I.M. Diclofenac and anti-emetic

Avoid opiates

Sort out the migraine

Case 3

55 year old male.

New headache. L temporal. Fluctuating in intensity. Featureless. Examination normal.

What would you do?

•Can be bilateral•Systemically unwell•Tender artery with allodynia•CRP better than ESR•Problem with skip lesions

Temporal arteritis

CASE 4•26 year old pole dancer•Headache with intercourse•What questions would you ask her?•Any investigations?•Treatment?

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

Non specific headache Tinnitus Two examinations What is most likely diagnosis?

Low Pressure Headache

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?

Cluster - Autonomic Cephalopathy

High impact ++ Peri-orbital clusters 15mins - 3 hours Cluster attacks and periods Unilateral autonomic features Acute or chronic

Cluster treatment

Injectable Sumatriptan

Nasal Zolmitriptan

Short term steroids

Oxygen 100%

Verapamil

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?

Have you ever had migraine?

Do you have problems with your neck?

What pain killers are you taking?

To scan or not to scan?

Medication overuse headacheMedication overuse headacheH

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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

Primary Tumours

Meningioma 20% - 10 yr survival 80%

Glioma 70% - 5yr survival 20%

Misc. 10% - Variable

Headache and tumour

Headache prevalence with tumour 70%+

Headache at presentation 50%

Headache alone at presentation 10%

(Iverson 1987)

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%

We need to scan when the advantages out way the

disadvantages

Reassurance, Cost, exposure Diagnosis/treatment incidental pathology

(4-10%)

Luftwaffe pilots (n-2370) Weber 2006

93% normal (25% variations of norm)

6.7% abnormalities

56 cysts; 13 vascular abnormalities;4 adenomas; 4 tumours

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

Probability of significant morbidity or mortality >1%.Need urgent investigation

Abnormal neurological symptoms or signs

New seizure

History of cancer elsewhere

Red Flags

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

The delivery of headache services

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”.

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

Commissioning headache service delivery

BASH 2001, ABN 2010

GPs first line management

GPSI support

Tertiary headache centres

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

Thalamus +Mid Brain structures

Medication overuse headache

Tension type headache

AURA

CERVICALNUCLEI

MIGRAINECENTRE

HypothalamusCLUSTER

Headache model

Secondary Headaches

Primary Headaches

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?

Migraine

Prodrome 60% Aura 30 % Headache (30% bilateral) Postdrome

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.

In practice

Recurrent headache that bothers

Nausea with headache

Light bothers

Implications for gastric stasis and neck pain

MigraineAcute treatment

Paracetamol, Aspirin, Domperidone.

Triptan

Triptans

Sumatriptan 100mg Sumatriptan 50mg Rizatriptan 10mg Zolmitriptan 2.5mg Eletriptan 20mg/40mg

Almotriptan 12.5mg

Naratriptan 2.5mg Frovatriptan

Triptan Half Life

Triptans – some practical points

Treat early Failure not class effect Not in CVD SSRIs Over 65 years

CASE 7b

Jane’s headaches become more frequent. When would you instigate prevention?

What is your first choice?

Migraine treatmentPreventative

When to instigate?

What to use?

How long for to assess an effect?

What rate dose increase?

How long on preventative medication?

• Beta blocker ++ (L)• Pizotifen + - (L)• Amitriptyline +• Gabapentin +• Sodium valproate + +• Topiramate +++ (L)• Calcium antagonists + -• Lisinopril, Montelukast + -• Clonidine - - -• Methylsergide ++(L)

Migraine prevention +- evidence and licence

CASE 7c

Jane has come for contraceptive advice.

What options does she have?

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

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?

Oestrogen sensitive migraine

Menstrual (pure - 7%, and other times

35%)

Peri-menopausal

Menstrual Migraine

Tricycle OC

Regular NSAI

100 mcg oestrogen patch

Regular long acting Triptan

Peri-menopausal migraine

Too much oestrogen too quickly - worse

25 mcg Evoral patch in quarters

Avoid oral oestrogen

Reassure will get better

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?

HeadacheA complex biopsychosocial interaction

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

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

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

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

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

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

Features childhood migraine

Pain is shorter acting More likely to be bilateral Often “mixed” Associated with other systemic

presentations

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

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

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

Management

Avoidence of triggers Analgesia +-Domperidone Sumatriptan nasal

Pizotifen Propranolol Amitrip Topiramate

School Policy Guidelines. RCGP, Headache UK, RCN

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

Diagnosing the right headacheThree Key Questions

2 - How many types of headache do you recognise?

Diagnosing the right headacheThree Key Questions

3 - What pain killers are you taking?