Headache Back to Medical School 2011

The Approach Don’t despair Rule out emergencies (History) Brief exam Get the patient to keep a diary Get the patient to see optician ?book longer appointment

Warning features in the history Headache that is new or unexpected in an individual patient Thunderclap headache (intense headache with abrupt or “explosive” onset) Headache with atypical aura (duration >1 hour, or including motor weakness) Aura occurring for the first time in a patient during use of combined oral contraceptives New onset headache in a patient older than 50 years New onset headache in a patient younger than 10 years Persistent morning headache with nausea Progressive headache, worsening over weeks or longer Headache associated with postural change New onset headache in a patient with a history of cancer New onset headache in a patient with a history of HIV infection.

1. How many different headache types does the patient experience? Separate histories are necessary for each. It is reasonable to concentrate on the most bothersome to the patient but others should always attract some enquiry in case they are clinically important. 2. Time questions a) Why consulting now? b) How recent in onset? c) How frequent, and what temporal pattern (especially distinguishing between episodic and daily or unremitting)? d) How long lasting? 3. Character questions a) Intensity of pain b) Nature and quality of pain c) Site and spread of pain d) Associated symptoms 4. Cause questions a) Predisposing and/or trigger factors b) Aggravating and/or relieving factors c) Family history of similar headache 5. Response questions a) What does the patient do during the headache? b) How much is activity (function) limited or prevented? c) What medication has been and is used, and in what manner? 6. State of health between attacks a) Completely well, or residual or persisting symptoms? b) Concerns, anxieties, fears about recurrent attacks, and/or their cause

42 yr old man 2 weeks ago developed very severe headache during sexual intercourse. Wife wanted to call an ambulance but he resisted as headache slowly subsided. Phoned up today because pain wasn’t settling and when he attempted sex again, he felt the pain building up and had to stop. Key questions in the history?

42 yr old man (2) Did you lose consciousness? Any visual disturbance? Vomiting? Persistent headache? Neck pain/stiffness? Previous history? Family history? Examination findings? Do you send to hospital?

42 yr old man (3) What is emergency doctor supposed to do? (because this does have a bearing on acute and subsequent management and you will almost certainly have to explain it to him!) Supplementaries: Family member with subarachnoid haemorrhage Patients with aneurysms Patients with polycystic kidneys

48 year old woman New, rather chronic headache and feels terrible Can’t concentrate, moody, appetite affected P.M.H. Migraine but they were entirely different Key questions in the history?

48 year old woman (2) Menstrual history Menopausal symptoms Can you give her HRT? (N.B. Similarities with polycystic ovary syndrome) Investigations and management?

62 yr old woman Persistent, nagging left-sided head pain for 3 weeks Fed up with it- gone off food, not sleeping well No previous history of headache Key questions in the history? Important examination findings?

62 yr old woman (2) Tender? Pain on eating? Muscle stiffness? P.V. and/or E.S.R. Methylprednisolone 500 mg reducing rapidly while biopsy is arranged Should be dramatic relief

35 yr old man 12 months constant pain “Not a headache – it’s a pain” Tight hat or head exploding May be intermittent in some Makes him frown Takes painkillers, “To take the edge of it” “Like a 6 inch nail” stabbing pains Pain up neck etc

35 yr old man (2) History is of pain without feeling unwell Furrowed brow Cords in neck region Rippling muscles in temples and jaw May overlap with migraine Do you scan?

25 yr old woman Headache started when she was a teenager May feel elated or weird the day before May wake up with pain in forehead Gradually worse – has to go to bed Dreadful pain – only relieved when I go to sleep May come back the next day 2-3 per month Key questions?

25 yr old woman (2) Take a detailed history Car sick? IBS? Family history? Related to periods? Premonitory symptoms Aura Pain Associated symptoms ?examination

25 yr old woman (3) Plenty of exceptions: Basilar migraine Pain isn’t bad enough for migraine Can be bilateral Aura may be strange Onset may be >40 without headache

40 yr old man Agonising needle pain in left eye Banging head on wall Every night it wakes him at 2 am Settles within 1 hour Had it once before for 6 weeks; then it went Family all have migraine Key questions?

40 yr old man (2) Does the eye go red or water? Does the lid droop? Nasal congestion or runny nose? Effect of alcohol? Smoker? Do you want to go to bed when it strikes?

30 yr old woman Generalised headache building up over weeks Feel sick with it Worse when I wake up Eases later in day Not feeling right – a bit off balance Key questions?

30 yr old woman (2) General health and previous history Balance Speech Vision Effect of neck position

35 yr old woman Chronic head pain Worse every morning but no nausea The only thing that helps a bit is to take painkillers

Examination Spend as much time as you can on history but direct questions General features ?frowning? Blood Pressure Vision Fields Pupils Discs Head and Neck Limb posture Reflexes Balance

Investigations Blood tests? Head scan? Lumbar puncture?

Treatments Physical treatments Analgesia Specific migraine treatment Prophylaxis Reassurance and understanding If no improvement, review

Migraine ?avoid caffeine etc ? Regular food and sleep Stratified strategy Use for at least 3 attacks Paracetamol or aspirin plus domperidone NSAIDs ?suppositories Triptan (Bandolier) N.B. 30% may not respond Prophylaxis Pizotifen, Betablockers, Amitriptyline, Topiramate, Valproate

Tension headache Check eyes at optometrist (I.I.H.) Rule out anaemia, Carbon monoxide, Healthy lifestyle? Physical treatments ?Biofeedback Amitriptyline/ Mirtazapine/ Venlafaxine Review diagnosis

Cluster headache Reassure Triptan drug ?nasal ? Subcut? Prophylaxis Verapamil Steroids Oxygen Lithium Methysergide

Special circumstances Young Pregnant Contraception HRT