Clinical Lead for Prevention/CCG Chair Consultant Neurologist Headaches Dr Clare Highton Clinical Lead for Prevention/CCG Chair Dr Richard Sylvester Consultant Neurologist

GP First outpatient attendances for Neurology Rate per 1,000 patients

Neuro first appointment rate per 1000 vs advice line rate per 1000

Use of neurology advice line - rates per 1,000 patients

Case 1 Mrs Maitland is 47 and has had back pain for many years. She is on ESA, and is stressed as they have told her she is fit for work, and has recently asked you for a letter to support her appeal. Her 14 year old daughter has learning disabilities. She now consults for a headache that is dull, present most days, mainly on the left, with nausea and some photophobia when it is at its worst. No neurological symptoms. Anything else you want to know? Management plan?

Case 2 Ms Scott is 25 and has suffered from classic migraine since puberty, with a strong FH. She rings duty doc because she has developed a migraine, and took rizatriptan as usual. She now has intense tingling on her left side and says she is having some difficulty with her speech. What would you do?

Case 3 Mr Rowley is 51, and has asked for a repeat prescription of his sumatriptan. He rarely consults, and self manages. Medication review done by phone last year. You notice his usage has crept up and he has used an average of 12 for the last 3 months Would you issue? Do anything, and if so what?

Case 4 Mr Tindal is 23, and he and his 19 year old brother devotedly care for their mother who has schizophrenia and dementia, with challenging behaviour. He also works in the City. He consults on Monday morning, as he had had to attend A&E on Sunday with a very severe headache that came on very suddenly while he was cycling over the marshes. You don’t have the A&E report, but he says he had a CT scan which didn’t show a bleed. His headache is slightly less intense but still very bad, and he has vomited in the early hours. He doesn’t usually get headaches.

Migraine Diagnosis Recurrent episodes - moderate to severe Unilateral (bilateral 30%) +/- pulsating/crushing +/- Aura (only minority of patients) Lasts 4-72 hours, if longer consider chronic migraine Associated nausea +/- vomiting, dislike of movement/ sound/light. Can be subtle. May have +ve childhood history of travel sickness Main triggers include – stress, relaxation, tiredness, hunger, oestrogen withdrawal, exercise, alcohol

Migraine Management Acute Oral triptan + NSAID / paracetamol. Oral sumatriptan (50 mg or 100 mg) If monotherapy is preferred, offer an oral triptan, or NSAID, or aspirin (900 mg every 4–6 hours - maximum of 4 g daily), or paracetamol. Consider adding an anti-emetic (such as metoclopramide, medomperidone, or prochlorperazine) even in the absence of nausea and vomiting. Prophylaxis – need high dose for 6 weeks to see effect 1st line: Propranolol 80-160mg/day (licensed) 2nd line: Topiramate 100-200 mg/day (licensed) 3rd line: Amitriptyline 10-100mg/day (off-label) Try two prophylactic drugs – each for 3 months before referral. Refer to IAPT for psychological support coping strategies NB migraine with aura or neurologic deficit avoid COCP. Exclude MOH as complicating factor.

Medicine Overuse Headache (MOH) Diagnosis Use of analgesics >2 days/week Confirmed when symptoms improve after analgesics withdrawn Management Identify and stop causative analgesics and Triptans. Use PRN antiemetic Headache may get worse for a few days/weeks before improvement Only if intolerable consider replacements eg naproxen 250-500 mg bd, avoid opiates including codeine Often after 4 weeks the primary headache (usually migraine) will emerge and need treatment Refer to IAPT for psychological support coping strategies

Tension Type Headache (TTH) Diagnosis Mild-moderate intensity Episode lasting 30 minutes to 7 days Unilateral or generalised Described as pressing/tightness Often spreads into or arises from neck Lacks specific features associated with migraine Not aggravated by physical activity Often associated with stress/anxiety/depression, sleep deprivation Confirm not MOH

Tension Type Headache (TTH) Management Reassure/identify contributing factors. 1°prevention Regular exercise Physio if neck symptoms Lifestyle changes: Relaxation therapy, psychological support referral to IAPT, yoga, meditation to ↓stress, explore family issues. Medication If symptoms ≤ 2 days per week ie episodic try: Aspirin/Paracetamol/ Ibuprofen/Naproxen Otherwise consider: Amitriptyline 10- 150 mg/day. If not tolerated try Nortriptyline 10-50mg/day or acupuncture

Cluster Headache Diagnosis Severe intensity unilateral peri-orbital pain Episodes last 15-180 minutes Associated agitation/pacing Rare 0.05% prevelance Ipsilateral autonomic features Clusters of attacks lasting 6-12 weeks

Cluster Headache Management Acute 1st line: Subcut injection 6 mg Sumatriptan most effective Prednisolone 60 mg OD reducing by 10 mg every 2 days can halt clusters Oxygen Specialist Initiation Only 100% 10-12l/min for 10-20 minutes Prophylaxis, after specialist advice Refer to neurology outpatients

Any questions?