Headaches Feedback from BASH 3rd Nov 2017

DemogrAphics Problem for 40% of adult population in UK Migraine affects 15% of adult population woman to men 3:1 190000 attacks/day mostly in productive years 100000 people off/every day costing economy 1.5 billion/annum Cluster headaches less common-0.05% prevalence Medication overuse headaches in 2 % of adults most primary headache presentations are related to migraine(90%)

International Classification of Headache Disorders Primary headaches Migraine Tension type headaches Cluster headaches Secondary headaches Attributed to head/neck trauma vascular disorders non vascular disorders withdrawal infection facial pain psychiatry Neuralgias trigeminal neuralgias

History taking Important Time Questions Character Questions Cause Questions Response Questions Health between attacks Questions

Migraine Recurrent moderate to severe headaches Lasting 1-3 days Associated with gastrointestinal symptoms Activities limited during attack Prefer dark/quiet Free of symptoms between attacks Chronic migraine rare-more than 15 days a month

Tension type headaches Attack -like episodes Low frequency Lasting several hours Usually unilateral,can be generalized Pressure/tightness/pulsating Disabling No associated symptoms Associated with stress/functional cervical musculoskeletal abnormalities

Cluster headaches Mostly in men Usually in their 20’s Often smokers Bouts of 6-12 weeks once/year Intense pain Mainly focused on one eye Often at the same time (after been asleep for 1-2 hours) Autonomic features unilateral conjunctival injection lacrimation blocked nose ptosis-Horners Alcohol/smells /sleep /exercise can trigger headaches

Medication overuse headaches 1 in 50 adults suffer from MOH Woman to men 5:1 Primary medications Triptans combination analgesia containing barbiturates/ caffeine/codeine Worst in morning Increased by exercise Over time episodes become more frequent Using medication more than 3 month and more than 15 days/month

Differential Diagnosis Often structural neck problems-aggreviated by movement Should not be attributed to sinus disease unless having other symptoms Should not be attributed to ear/TMJ/Teeth unless having other symptoms

Concerning features New headaches Thunderclap headaches During time on combined oral contraceptive medication Older than 50 and new headaches Persistent morning headaches with nausea Progressive headaches History of cancer HIV

Features of high pressure headaches Wakes patient up Cough headaches Pulsatile tinnitus Seizures Cognitive change Papilloedema

ED presentations Migraine 55% Tension type headaches 25% Cluster headaches 7% Secondary headaches 13% ? scan/not to scan-?CT/?MRI No big impact on survival rates by early scanning

Examination History! Optic fundi BP-but rarely the cause Neck/TMJ examination Only 0.9% of consecutive headache patient without neurological symptoms had significant pathology

Serious causes of headaches Intracranial tumors produces rarely headaches until quiet large only 3-4% present as headaches (1 in a million) of population per year exception are frontal lobe-presenting with personality changes Meningitis SAH Giant Cell Arteritis Primary angle closure glaucoma IHH CO poisoning

Treatment Migraine in pregnancy Paracetamol Aspirin/NSAIDS-except third Trimester Triptans-Sumatriptan appears safe Metoclopramide Breast feeding Ibuprofen/diclofenac Sumatriptan-no breastfeeding for 12 hours Cluster headaches Oxygen Sumatriptan nasal 3/day Verapamil up to 960 mg/day

Idiopathic intracranial hypertension Obese women in childbearing age Presenting with papilloedema normal neuro examination normal neuro imaging LP pressure more than 25 but elevated pressure only makes diagnosis if also other symptoms present also if LP relieves symptoms-not diagnostic ! Papilloedema important not to miss OCT scanning-discuss with ophthalmology has not to be symmetrical MRI empty Sella possible feature of IHH presenting with visual loss needs urgent surgical shunt last resort-high revision rates always consider venous sinus thrombosis Anaemia Tetracycline Nitrofurantoin

ED presentation with IIH ? papilloedema-?need OCT Check bloods regarding infection/anaemia ? blocked shunt Consider Migraine Medication overuse headaches low pressure headaches Rarely Ct head useful