Headaches – tips and tricks Dr Luke Bennetto Consultant Neurologist Frenchay Disclaimer: These slides are intended to be viewed as part of an oral presentation which adds necessary context. Statements within the slides should not be relied upon outside of this context.

1. Headache is very interesting! Why do human heads hurt so much?

1. Heads are very good at hurting – they rarely need a good reason. Secondary headache is rare. Primary headache is very common. Brain tumour virtually never presents as headache to a secondary care neurology clinic

2. Tension headache is mythological Tension type headache is even rarer than headache secondary to brain tumour in a neurology clinic

Migraine 3. Primary headache Tension Cluster CPH SUNCT Idiopathic stabbing Hypnic

4. There are more treatment options for migraine

How to turn tension into migraine What do you do (or want to do) when you get a headache? (Not does light bother you)

How to turn tension into migraine What was the headache like when it first started? No, think carefully – did it come and go…did you feel sick…did you have to take painkillers regularly to stop the bad headaches

How to turn tension into migraine Does anyone in the family have bad headaches where they feel sick and have to go to bed?

Mild Migraine/Tension Severe migraine

5. ‘The best treatment for migraine is a bar of chocolate’ Dietary triggers are over rated. Prodrome often includes specific food cravings and these may be successful in aborting the migraine, but when they fail we blame the food.

6. Treat early and effectively Put the fire out early If infrequent – then take analgesia as soon as you think ‘I’m not having a headache am I’ Dispersible aspirin 1g Consider anti-emetic to aid gastric absorption

7. Avoid narcotics at all costs

8. Educate about medication overuse Avoid painkillers on more than 2 days per week

9. Triptans No more effective than simple analgesia but work in some patients where simple analgesia ineffective. Preferable to opiates. Rarely work when there is ‘allodynia’. Very safe. Triptan sensations. Sumatriptan, rizatriptan, zolmitriptan, naratiptan, almotriptan, frovatriptan.

10. Preventatives are more important than analgesia withdrawal Amitryptiline Propanolol/Metoprolol Topiramate Valproate

11. Start low and go slow

12. Modest goals (lower expectation) In chronic headache aim for 50% reduction in headache in 6 months. Impatience leads to effective medication being discarded too early

13. Trigemino-cervical complex

14. Thunderclap headache All headache is sudden onset 2 minutes, 1 hour. Can a primary or secondary headache syndrome be diagnosed? How often have they had it? How long does it last?

15. Best way to separate cluster from migraine?

16. Best way to separate trigeminal neuralgia from TACs?

Trigeminal Autonomic Cephalalgia Cluster (30-120 minutes) Paroxysmal Hemicrania (2-30 minutes) SUNCT/SUNA (10-240 secs)

17. Indomethacin Powerful NSAID Switches off Chronic Paroxysmal hemicrania Suggest trying in patients with refractory side locked headache

18. Giant cell arteritis does not occur under the age of 50 Never Ever Or at least the risk of considering the diagnosis exceeds the benefits.

19. GCA can occur with normal Plasma Viscosity But almost certainly not with normal PVisc, CRP and platelets.

20. Internet Exeter headache clinic OUCH UK

Any questions?