Headache for Optometrists

Dr Paul Davies

Consultant Neurologist

23rd February 2010

The West Wing

Headache for Optometrists

1. Over-view of Headache

2. Common benign headaches

3. Serious headaches

(with some ocular/visual emphasis)

Headache in the UK

• Affects nearly everyone occasionally• Is a problem for around 40% of people • Is one of the most frequent causes of

consultation in both general practice (4% of all adults/year) and neurological clinics (25% of all new referrals)

• Represents an immense socio-economic burden

Migraine in the UK

• Affects 12-15% of the population

• Affects 3X more women than men

• Most troublesome late teens to early 50s (working lives)

• Also occurs in children and the elderly

www.i-h-s.org

Primary Headache“Headache is an integral part of the

syndrome…diagnosis is symptom based.”

Secondary Headache“A de novo headache occurring with

another disorder recognised to be capable of causing it….diagnosis is

aetiological”

Headache ClassificationPart 1: The Primary Headaches

MigraineTension-type headacheCluster headache and other TACs

 Part 2: The Secondary Headaches

Headaches attributed to:- Head and/or neck traumaCranial or vascular disorderNon-vascular intracranial disorderA substance or its withdrawalInfectionDisorders of homeostasisDisorders of

cranium/neck/eyes/ears/nose/sinusesTeeth/mouth

Psychiatric disorderPart 3: Cranial Neuralgias

Life-time Prevalence of Symptomatic and Non-symptomatic Headaches in a General Population

Disorder %Migraine without aura 9Episodic TTH 66Idiopathic stabbing 2External compression 4Cold stimulus 15Benign Cough Headache 1Headache associated with sexual activity 1Hangover 72Fever Headache 63Head Trauma 4Metabolic (fasting) 19Disorders of the neck, eyes, ears 1, 3, 0.5Disorders of the nose/sinuses 15

Ref: Rasmussen and Olesen Neurology 1992;42:1225-1231

Differential diagnosis of 906 patients who presented to a general neurology clinic with headache or facial pain as

the major or only symptom

Diagnosis Number %Tension headache 296 32Migraine 241 27Headache ? Cause 139 15Post-traumatic 71 8Facial pain ?cause 38 4Depression 29 3Trigeminal neuralgia 29 3Cluster headache 19 2Malignant IC Tumour 14 1.5Benign IC Tumour 9Temporal arteritis 6Post-herpetic neuralgia 5Benign IC hypertension 4Cough headache 3Subdural haematoma 2Sinus infection 1

Primary Headaches

1. Migraine

2. Tension-type headache

3. Cluster headache and other trigeminal autonomic cephalalgias

4. Other primary headaches

– Primary stabbing/cough/exertional/sexual activity/thunderclap

– Hypnic

– Hemicrania continua

– New daily-persistent headache

Migraine

Headache/Pain with Visual/Occular Symptoms or Signs

Migraine

Migraine without Aura

Migraine with Aura

Migraine Aura (No or little headache)

Steiner TJ et al. Cephalalgia 2003; 23:519-527

7.6%7.6%

18.3%18.3%

14.3%14.3%

0022446688

101012121414161618182020

Overall Females Males

% o

f U

K p

op

ula

tio

n

Gender-related prevalence of migraine

Age-related prevalence of migraine

Females

Males

Age (years)

00

55

1010

1515

2020

2525

3030

Mig

rain

e p

rev

ale

nce

(%

)30302020 4040 5050 6060

The burden of migraine

Prevalence

• Migraine is most common during the productive years

Lipton RB et al. Headache 2001; 41:646-657

Severeimpairment/

bed rest

Normal function

Some impairment53%53%

9%9%

38%38%

The burden of migraine

Disability due to migraine

• 91% of migraine patients report disability

Trigger Factors for Migraine

1. Stress – relaxing

2. Hormonal changes in women

3. Sleep deprivation/lying in

4. Dietary changes

5. Environmental stimuli

6. Combinations

There may not be any!

The Triptans

Imigran (Sumatriptan)

Zomig

Naramig

Maxalt

Relpax

Almogran

Migard

Preventative Drugs

Beta-blockers

eg propranolol, metoprolol, atenolol

Epilim (sodium valproate)

Topamax (topiramate)

Tricyclic antidepressants eg amitriptyline

Calcium blockers

Sanomigran (pizotifen)

NSAID’s

Tension-type Headache

Headache/Pain with Visual/Occular Symptoms or Signs

Tension-type headache

? Due to refractive errors

? Due to squint

? Relate to wearing glasses

Cluster Headache

Horner’s Syndrome in CH

• Appears during attack

• May persist between attacks

Cluster Headache (Migrainous Neuralgia)

• Fairly rare disorder - prevalence 0.1 %• Male:Female ratio approx. 5:1• Usually a primary headache disorder;

occasional post-traumatic cases, or rarely secondary to pituitary tumour or aneurysm

• Occasional familial cases (4-7%)• Majority of sufferers enthusiastic smokers

Episodic Cluster Headache

• Onset typically 20-30, occasionally older• Bouts of attacks lasting 1week to 4 months• Bouts 1-2/year, often seasonal (spring, autumn)• Sometimes long remissions lasting years• Sensitive to triggers only in bouts• 10-20 % go on to chronic CH

Headache/Pain with Visual/Occular Symptoms or Signs

Primary Headache SyndromesMigraineCluster headache and other Trigeminal Autonomic Cephalalgias (TACs)SUNCT (short-lasting, unilateral, neuralgiform headache with conjunctival injection and tearing)

Cranial NeuralgiaTrigeminal Neurlagia

Headache/Pain with Visual/Occular Symptoms or Signs

• Corneal ulcer• Sceritis/Episcleritis• Glaucoma• ?Retinal Migraine• ?Opthalmoplegic Migraine• Optic Neuritis• Pituitary Tumours

Are all Secondary Headaches

Serious Causes of Headache

Red Flags in Headache History

• Sudden onset severe headache• New headache in old people• Headache with coughing/straining• Persistent morning headache with nausea• Steadily worsening headache

Note: Serious causes of headache may have no abnormal signs

Dealing with Headache

1. Is it serious? The patient’s view

2. If not, what is it due to? Diagnosis? Explanation?

3. Management and treatment

Goals. Realism