Steve Elliot GPwSI Headache

History taking in episodic headache History taking in chronic headache 3minute neurological examination Who to refer for scanning (Management of headache)

“Listen to the patient. He is telling you the diagnosis” Sir William Osler ( )

“The headache history has to be taken, not received” Professor Peter Goadsby

Why does it matter? Headache is not a diagnosis Clear diagnostic criteria Diagnosis before treatment Disease specific treatments

Guatama Buddha BC How to relieve suffering

8 questions - the way to end suffering in headache Location? Character? Severity? Aggravation by movement? Nausea/vomiting? Photophobia? Phonophobia? Duration?

IHS tension headache 2 of Bilateral Pressing./tightening/non pulsating quality Mild to moderate intensity Not aggravated by movement No more than 1 of Nausea/vomiting Phonphobia or photophobia Duration 30minutes to 7days

IHS migraine Need 2 out of: Unilateral Moderate-severe Throbbing Worse with movement Need 1 of Nausea and/or vomiting Photophobia and phonophobia Duration 4-72 hours

SIGN guidelines “Neuroimaging is not indicated in patients with a clear history of migraine,without red features for potential secondary headache,and a normal neurological examination”

Cluster headache Side locked unilateral Peircing /drilling/grinding Very severe Not worse with movement Possibly nausea/vomiting Possibly unilateral photophobia Possible phonophobia minutes duration Autonomic symptoms Restless

Landmark study 1203 patients GP diagnosis of primary headache Headache diary for 3months Diaries analysed by blinded assessors Findings: 94% migraine or probable migraine 82% “tension type headache” had migraine

“Brain attack” Trigger – Dorsal pons Prodrome - Hypothalmus Aura – Cerebral cortex Peripheral sensitisation – Cranial vasculature Central sensitisation – Thalamus Nausea/vomiting- Area Postrema Autonomic symptoms – Parasympathetic system Neck pain – Sensitisation of C2/C3

Why me? Blame your parents Chemical imbalance Your brain is different Symptoms between attacks

Chronic headache 2-3% of population have headache on more days than don’t Half of above have medication overuse 2%/year migraine transforms to chronic Most preceded by episodic headache Co-mordidities anxiety,depression,obesity Difficult to manage

Causes chronic daily headache Primary headaches Chronic tension type headache Chronic migraine Chronic cluster headache Medication overuse headache New daily persistent headache Hemicrania continua

History in chronic headache Pattern Low grade all time? Low grade with exacerbations? Short lasting frequent? Stable or progressive? 8 questions Medication including OTC? Caffeine consumption? Exclude red flags

What not to miss Idiopathic intracranial hypertension Low pressure headache Giant cell arteritis Other secondary headache REMEMBER High pressure headache WORSE on lying flat Low pressure headache BETTER lying flat

How to perform a headache examination

3minute headache examination Romberg Palm drift Pupil responses Fields Play piano Finger-nose Tandem gait Facial movements Eye movements Fundoscopy Protrude tongue Limb and plantar reflexes Corneal reflexes

Don’t forget BP Palpate temporal arteries >50 ESR/CRP >50 DOCUMENT WHAT YOU DO

Neuroimaging guidelines - a brief summary

What do we know? Incidence of brain tumour in general population is % per year 72% occur over age 50 In primary care risk of brain tumour with headache presentation is 0.09% If GP makes diagnosis of primary headache risk is 0.045% If GP cannot make diagnosis then risk is 0.15%

NICE, TWW and headache Headaches in whom a brain tumour is suspected Headache of recent onset accompanied by features suggestive of raised intracranial pressure eg Vomiting Drowsiness Posture related headache Pulse synchronous tinnitus Or by other focal or non-focal neurological symptoms eg blackout,change in memory or personality New, qualitatively different,unexplained headache that becomes progressively severe

But... Tension type headache 58-77% of brain tumours Migraine like in 7-9% but atypical features Intermittent headache in 62-88% 8% headache as only symptom 74% brain tumours present within 3months 90% within 6 months Brain tumour headache may be similar to previous headache but more frequent/severe and associated with new symptoms

Red flags-SIGN guidelines New onset or change in patient over 50 New onset headache with history of cancer Abnormal neurological examination Headache that changes with posture Headache that wakes (most common migraine) Headache precipitated by physical exertion/Valsalva Non focal neurological symptoms eg cognitive disturbance) Patients with risk factors for CVST Jaw claudication or visual disturbance Neck stiffness Fever Change in headache frequency,characteristics or associated symptoms Thunderclap headache Headache that changes with posture New onset in patient with HIV

Red flags-BASH guidelines Risk of underlying tumour >1% Warrant urgent investigation Papilloedema Significant alterations in consciousness,memory,confusion or co-ordination New epileptic seizure New onset cluster headache (non urgent) History of cancer elsewhere particularly breast or lung

Orange flags -BASH Probability of an underlying tumour 0.1-1% Careful monitoring and low threshold for investigation New headache where diagnosis not clear after 8weeks Abnormal neurological exam or other neurological symptoms Headache aggravated by exertion or Valsalva’s manoeuvre Headaches associated with vomiting Headaches which have been present for some time but have changed significantly, particularly rapid increase in frequency New headache in patient over 50 Headache which wakes from sleep Confusion

Yellow flags- BASH Probability of underlying tumour between 0.01 and 0.1% Need for follow up not excluded Diagnosis of migraine or tension type headache Weakness or motor loss Memory loss Personality change

Acute medication in migraine Paracetamol Aspirin 900mg Naproxen 500mg Domperidone if nausea Consider suppositories Almotriptan 12.5mg Other triptan if Almotriptan ineffective Zolmitriptan nasal spray Sumatriptan injection

Prophylaxis Propranolol mg Amitriptyline mg Pizotifen if young Topiramate or Epilim Take 6-8 weeks to kick in See regularly

Don'ts in migraine treatment Over the counter Opioids Caffeine Migraleave Analgesia more than 2-3 days per week

Sir William Osler again “One of the first duties of the physicians to educate the masses not to take medicines”

Medication overuse headache Headache >15 day per month Intake of following for 3months Simple analgesia >15 days per month Or Opioids/triptans/combination analgesia >10 days per month Headache resolves or returns to previous pattern within 2months of discontinuation of analgesia

What do you do when you get a headache? Stay still =Migraine Pace up and down = Cluster Take tablet = Medication overuse

Management of chronic headache Exclude red flags Establish phenotype Lifestyle measures Avoid caffeine Stop analgesia (Occasional Naproxen) Start prophylaxis according to phenotype Regular follow up

“ The very first step towards success in any occupation is to become interested in it” Sir William Osler ( ) Canadian Physician