Andrew Graham Consultant Neurologist June 22 2016 Headache Andrew Graham Consultant Neurologist June 22 2016

“The patient with a headache often finds himself a medical orphan “The patient with a headache often finds himself a medical orphan. He is fortunate indeed if his headache is transient, for otherwise he may find himself on an excursion to the ophthalmologist, otolaryngologist, neurologist, dentist, psychiatrist, chiropractor, and the latest health spa. He is x rayed, fitted with glasses, analysed, massaged, relieved of his turbinates and teeth, and too often emerges with his headache intact” RC Packard 1979

Headaches Primary care consultations Neurology OPD 30% 6.4 /100 women 2.5/100 men Neurology OPD 30% Life time prevalence of headache >90%

Headache Can I classify this headache? Do I need to investigate? What does the patient want? Is treatment appropriate? And if so what is the most sensible approach?

Can I classify this headache? History Periodicity Associated features Behaviour during headache Family history Current medication Social situation/stressors

Can I classify this headache? Primary headache Secondary headache Migraine Tension type headache Cluster headache and other trigeminal autonomic cephalalgias Other primary headaches Medication overuse headache GCA Acute narrow angle glaucoma Lesions and structural causes Raised intracranial pressure Low pressure headache Chronic meningoencephalitis Post brain insult headache

Primary headache syndromes Migraine (with or without aura) Tension type Cluster and other trigeminal autonomic cephalalgias Other primary headaches

Migraine characteristics Attacks of headache lasting 4 to 72 hours Nausea and/or vomiting Intolerance of light Intolerance of noise Recurrent attacks Visual or neurological aura lasting 6 – 60 mins Consistent trigger

Tension type headache Featureless headache Bilateral Tightening quality Mild to moderate severity Absence of features of migraine

Cluster headache Severe unilateral pain Rapid onset Autonomic features on same side 15mins to 3 hours duration 1-8 attacks a day Restless during an attack Striking circadian rhythm

Other primary headache syndromes Hemicrania continua Primary stabbing headache Primary cough headache Primary exertional headache Primary headache associated with sexual activity Primary thunderclap headache Hypnic headache

Secondary headache Need to consider Raised intracranial pressure Low pressure headache Chronic meningoencephalitis Post brain insult headache Giant cell arteritis Glaucoma Cerviogenic Disorders of eyes/ears/nose/sinuses/teeth Depression Vascular disorders

Secondary headache Need to consider Raised intracranial pressure Low pressure headache Chronic meningoencephalitis Post brain insult headache Giant cell arteritis Glaucoma Cerviogenic Disorders of eyes/ears/nose/sinuses/teeth Depression Vascular disorders

Headache concerning features New onset headache after age 50 Genuinely increasing frequency and severity Waking patient from sleep Unresponsive to treatment Always on same side Following head trauma Precipitated by exertion New headache in patients: On anticoagulants With HIV or cancer

General Examination Blood pressure Neck examination Temporal pulses Posture Range of movement Muscle tone Muscle tenderness Temporal pulses

Neurological Examination Fundoscopy Cranial nerves Tone, power, reflexes and coordination in all four limbs Plantars Gait including heel toe walking

Do I need to investigate? Headache syndromes where a structural explanation is plausible Localising neurological symptoms/signs not explained by aura Constitutional or systemic symptoms/signs Recent diagnosis/treatment for cancer Unclassifiable headaches New daily persistent headache

Investigations Blood tests: ESR, TFTs Doing a scan CT radiation risk and best for acute pathology MRI no radiation but risk of incidental finding can be up to 1 in 10

Scanning Prospective study new headache >4 weeks significant intracranial abnormality in: Migraine 0.4% Tension type headache 0.8% Cluster headache 5% Not clearly defined 3.7%

What does the patient want? Explanation Reassurance Treatment

Is treatment appropriate? Headache diary Avoid opiates

Medication overuse headache Most common culprits opiates-(codeine) and triptans Any acute symptomatic treatment can cause it Patients often under report what they are taking Need to stop all medication for 7-10 days Then consider preventative treatment

Management of tension type headache Lifestyle issues work-home-leisure balance exercise sleep Physical measures relaxation massage self-help Drugs limited simple analgesics Amitriptyline SSRIs

Acute migraine treatment Early analgesics Aspirin 600-900mg Ibuprofen 400mg Paracetamol 1G Analgesics plus antiemetics Metoclopramide Buccastem Triptans Rizatriptan 10mg Almotriptan 121.5mg Eletriptan 40-80mg

Prevention of migraine Consider if 2 or more attacks per month Beta-blockers- propranolol Topiramate Gabapentin Amitriptyline Valproate Pizotifen

Cluster headache Acute- oxygen or triptan (subcut or nasal) Prophylaxis -Verapampil

Review Classification of headaches Investigations and scanning Primary headaches Secondary headache disorders Investigations and scanning Patient expectations A sensible approach to treatment

Indications for referral? 1. Where specialist diagnosis is required 2. Clincal features suggest significant or serious neurological disease 3. Failure to respond to appropriate adequate treatment 4. Patient at high risk of serious disease 5. Reassurance

Further reading SIGN www.sign.ac.uk diagnosis and management of headache in adults: a clinical guideline NICE guideline CG150 Headaches: diagnosis and management of headaches in young people and adults