I’ve got a headach e ??? Headache David Kernick Exeter Headache Clinic

Migraine impact n Headache in top 10 of WHO disability index. n20% population – headache impacts on their quality of life (adults and children) n£3 billion per year in economic terms

When people come to see you what do they think they have?

nNeed glasses nBlood pressure nBrain tumour

What do patients have when they present to GP with headache?

What do patients have when they present to GP with headache? Landmark Study n85% migraine n10% Tension type headache n5% secondary headache n<1% other types of headache

What do GPs think when patients present with headache? (Kernick 2008)

Headache consultations in primary care nConsultation rates are low. 50% of migraine sufferers have never seen a doctor n10% are under continuing care nOne third of headaches will be incorrectly diagnosed.

What is happening in primary care? nLess than 20% will receive Triptan Walling 2006 n10% of those who would benefit from prevention receive it Rahimtoola 2005

Headache referral patterns n9% GP presentations are referred to secondary care(25% children) (Loughey) n % of neurology referrals are for headache (Hopkins)

What do patients have when they present to A and E with headache? Valade 2000 n – 9480 Average age admitted (3%)

nMigraine 55% nTTH25% nCluster 7% nTrauma1.6% nTrig Neuralgia1.6% nSinusitis1.6% nVascular disorders1.2% nLow Pressure1.2% nMeningitis 0.35% nTumour0.17% nOther Misc< 5%

Case 1 n35 year old male nThree week history nSharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively. nOne question? nTwo examinations? nWould you investigate?

Classifying headache

Where does the pain come from? Intra – cranial (dural pain fibres) nTension – raised intracranial pressure nCompression – tumour nInflammation - migraine,meningitis,blood

Where does the pain come from? Extra - cranial nArteritis nNeuralgia nMuscle tension nFacial structures

IHS Headache classification Primary Secondary nMigraine nTension type nAutonomic cephalalgias (cluster) nTraumatic nVascular nNon-vascular (SOL) nSubstance induced nInfection nDisturbed homoestasis nFacial structures

Activation anywhere in the system can lead to output in any other part of the system and vici versa

Thalamus + Mid Brain structures Medication overuse headache Tension type headache AURA CERVICAL NUCLEI MIGRAINE CENTRE Hypothalamus CLUSTER Headache model Secondary Headaches Primary Headaches

Case 1 n35 year old male nThree week history nSharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively. nOne question? nTwo examinations? nWould you investigate?

Two examinations nFundoscopy nBP n‎Giles Elrington neurological examination ‎

Case 1 n35 year old male nThree week history nSharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively. nOne question? nTwo examinations? nWould you investigate?

Headache Pathway EXCLUDE A SECONDARY HEADACHE nDo something now nDo something soon nDIAGNOSE A PRIMARY HEADACHE nExclude medication overuse and manage the primary headache

Case 2 You are called out to a 21 year old female who has had severe sudden onset headache. She is lying in a darkened room vomiting and is unable to move. What is the differential diagnosis?

Sub Arachnoid - thunderclap headache

Thunderclap headache - RVS n lasts 1-3 mths. nPrimary or secondary nNormal CT, LP. Needs CT angio. nCan get complications

Meningitis

Malignant hypertension

Migraine - The emergency call out nInjectable sumatriptan nI.M. Diclofenac and anti-emetic nAvoid opiates nSort out the migraine

Case 3 n55 year old male. nNew headache. L temporal. Fluctuating in intensity. Featureless. Examination normal. nWhat would you do?

Can be bilateral Systemically unwell Tender artery with allodynia CRP better than ESR Problem with skip lesions Temporal arteritis

CASE 4 26 year old pole dancer Headache with intercourse What questions would you ask her? Any investigations? Treatment?

Sex headache nPre orgasmic or orgasmic (10% SAH) nPrimary or secondary (vascular, tumour, Arnold Chiari) nLow threshold for investigation nTreatment nTechnique nB blocker nIndometacin nAvoid recreational drugs

nNon specific headache nTinnitus nTwo examinations nWhat is most likely diagnosis?

Low Pressure Headache

Case 5 A 34 year old man presents with pain around his left eye that he describes like a “red hot poker”. He has had a number of attacks over the last few weeks. With this presentation, what are the key questions you need to ask him to establish a diagnosis? What investigation will you do?

Cluster - Autonomic Cephalopathy nHigh impact ++ nPeri-orbital clusters 15mins - 3 hours nCluster attacks and periods nUnilateral autonomic features nAcute or chronic

Cluster treatment nInjectable Sumatriptan nNasal Zolmitriptan nShort term steroids nOxygen 100% nVerapamil

CASE 6 n45 year old female nDull continuous bilateral occipital pain nFeatureless nWorried as friend had brain tumour and wants a scan nThree questions? nDo you investigate?

nHave you ever had migraine? nDo you have problems with your neck? nWhat pain killers are you taking? nTo scan or not to scan?

Medication overuse headache Headache intensity Migraine attacks Frequent ‘daily’ headaches Withdrawal of all analgesia Return of episodic headache Increased frequency of headache, associated with increased frequency of analgesia use. Daily headache with spikes of more severe pain

Primary Tumours nMeningioma 20% - 10 yr survival 80% nGlioma 70% - 5yr survival 20% nMisc. 10% - Variable

Headache and tumour nHeadache prevalence with tumour 70%+ nHeadache at presentation 50% nHeadache alone at presentation 10% (Iverson 1987)

Risk of brain tumour with headache presenting to primary care (Kernick 2008) Risk % Undifferentiated headache Primary headache Under %0.03% Over %0.09%

We need to scan when the advantages out way the disadvantages Reassurance, Cost, exposure Diagnosis/treatment incidental pathology (4-10%)

Luftwaffe pilots (n-2370) Weber 2006 n93% normal (25% variations of norm) n6.7% abnormalities n56 cysts; 13 vascular abnormalities;4 adenomas; 4 tumours

In reality the inputs are complex nLimited poor quality evidence base nExpert opinion nMedico-legal case law nPatient-doctor characteristics and approach to uncertainty nOrganisational factors

Probability of significant morbidity or mortality >1%. Need urgent investigation nAbnormal neurological symptoms or signs nNew seizure nHistory of cancer elsewhere Red Flags

Headache presentations where probability is likely to be 0.1% and 1%. Need careful monitoring and low threshold for imaging nAggregated by Valsalva manoeuvre nHeadache with significant change in character n Awakes from sleep nNew headache over 50 years nMemory loss nPersonality change Orange Flags

The delivery of headache services

Secondary Care “The role of the specialist is to reduce uncertainty, to explore possibility and to marginalise error. Primary Care “The role of the GP is to accept uncertainly, to explore probability and to marginalise danger”.

GPs with special interest n NHS plan calls for GPSIs to provide local, efficient care n Controversy over concept from primary care n Limited evidence base n Substitution, complementation, meeting unmet need

Commissioning headache service delivery BASH 2001, ABN 2010 n GPs first line management n GPSI support n Tertiary headache centres

CASE 7 nJane is a 28 yr old nPresents with a visual disturbance lasting 30 minutes. No other symptoms nWhat are the key questions? nWhat is the differential diagnosis

Thalamus + Mid Brain structures Medication overuse headache Tension type headache AURA CERVICAL NUCLEI MIGRAINE CENTRE Hypothalamus CLUSTER Headache model Secondary Headaches Primary Headaches

CASE 7a nJane develops a pattern of visual disturbance followed by headache nWhat features would confirm a diagnosis of migraine? nHow would you manage the acute attack?

Migraine nProdrome 60% nAura 30 % nHeadache (30% bilateral) nPostdrome

Formal Migraine nAt least 5 attacks n4-72 hours (1-72 hours) nTwo of : unilateral, pulsating, moderate or severe pain, aggregation by physical activity. (bilateral) nAt least one of: nausea/vomiting, photophobia, phonophobia. (Can be inferred) nNot attributed to another disorder.

In practice nRecurrent headache that bothers nNausea with headache nLight bothers

Implications for gastric stasis and neck pain

Migraine Acute treatment nParacetamol, Aspirin, Domperidone. nTriptan

Triptans

Triptan Half Life

Triptans – some practical points nTreat early nFailure not class effect nNot in CVD nSSRIs nOver 65 years

CASE 7b nJane’s headaches become more frequent. When would you instigate prevention? nWhat is your first choice?

Migraine treatment Preventative n When to instigate? nWhat to use? n How long for to assess an effect? n What rate dose increase? n How long on preventative medication?

Beta blocker++ (L) Pizotifen+ - (L) Amitriptyline+ Gabapentin + Sodium valproate+ + Topiramate +++ (L) Calcium antagonists + - Lisinopril, Montelukast + - Clonidine Methylsergide++(L) Migraine prevention +- evidence and licence

CASE 7c nJane has come for contraceptive advice. nWhat options does she have?

What about the pill? Ischaemic stroke nFit women - 5/100,000 women years nWithout aura - 15/100,000 women years nWith aura - 30/100,000 women years nAvoid if other risk factors Eg smoking n?POP - probably safe

CASE 7d nAfter a few years, the migraines have settled to monthly and associated with menstruation only. She is fed up with taking regular prevention. nHow will you manage this?

Oestrogen sensitive migraine nMenstrual (pure - 7%, and other times 35%) nPeri-menopausal

Menstrual Migraine n Tricycle OC nRegular NSAI n100 mcg oestrogen patch n Regular long acting Triptan

Peri-menopausal migraine nToo much oestrogen too quickly - worse n25 mcg Evoral patch in quarters nAvoid oral oestrogen nReassure will get better

CASE 8 Jane brings in her 13 year old son who is getting trouble with headache. In view of the family history you suspect migraine. nHow do features in children differ from adults? nWould you image? nWhat treatment would you instigate?

Headache A complex biopsychosocial interaction

Primary Headache Epidemiology nHeadache most frequent neurological problem in children and commonest manifestation of pain n50% Childhood migraine becomes chronic and continues into adulthood n n<10% will see their GP

Primary Headache Epidemiology n10.6% migraine prevalence (3.4% age 5) n10% -24% tension type prevalence n0.01% cluster prevalence nInvariably mixed or not well defined

Why don’t children seek help? Mortimer 1992 nDon’t realise its migraine nOnly a headache nParents don’t want to reinforce illness behaviour nParents pattern their health seeking behaviour

What is happening in primary care? nGPs made diagnosis in 20% n25% referred to secondary care n3 in 10,000 tumour nNo tumours if migraine diagnosed Kernick Cephalalgia 2009

DiagnosisTotal in cases Total in controls LR (confidence intervals) Depression1.5%0.67%2.2 (1.9,2.5) Depression in year after headache presentation

Problems with Children under 3 years nUnable to articulate symptoms of raised intracranial pressure nProblem may be suggested by their behaviour in ways that may be relatively subtle

Features childhood migraine nPain is shorter acting nMore likely to be bilateral nOften “mixed” nAssociated with other systemic presentations

Presentation of Brain Tumour n40% headache (<10% headache alone) n28% nausea and vomiting n22% motor abnormalities n17% visual abnormalities n17% cranial nerve abnormalities n10% seizures n3% behavioural change Wilme 2010

Red Flags Discuss with Paediatrician the same day nAbnormal neurological sign nConfusion or disorientation nVisual abnormalities nAbnormal head position (double vision or neck pain) nCerebella dysfunction nPersistent headache for 4 or more weeks at presentation that awake from sleep or occur on waking nPersistent headache at any time in a child younger than 4 years nPersistent headache for 2 or more weeks with vomiting

Orange Flag presentations Need referral/close monitoring nHeadache with behavioural change nHeadache with deterioration in school work nHeadache with growth arrest or abnormal puberty nA persistent unilateral or occipital headache nA persistent headache in a child with a personal or family history of childhood tumour nRecent change in headache characteristics in a previous diagnosed primary headache

Management nAvoidence of triggers nAnalgesia +-Domperidone nSumatriptan nasal nPizotifen nPropranolol nAmitrip nTopiramate

School Policy Guidelines. RCGP, Headache UK, RCN

Diagnosing the right headache Three Key Questions 1 - What is the impact? n Migraine - lie down n Tension Type Headache - keep going n Cluster Headache - bang head against wall

Diagnosing the right headache Three Key Questions 2 - How many types of headache do you recognise?

Diagnosing the right headache Three Key Questions 3 - What pain killers are you taking?