A Guide for Doctors who do (with help from Practical Neurology Dec 2015 – Sinclair, Sturrock,Davies, Matharu)

Formerly of Burton and Bransgore Medical Centres

Mr M Aged 53 Sudden onset very severe h/a during sex at approach of orgasm. Vomited. Eventually got to sleep. H/a still present next morning although a bit better. Seen in practice that morning by a locum GP who referred him to neurology clinic (c&b). Partner heard about case and intervened; phoned consultant neurologist who arranged admission. Admitted to hospital 14 days later. CT brain normal. No LP. Reassured and discharged home. Attended c&b appointment 3 weeks later. Well no further episodes.

Mr P Aged 42 FH migraine. Occasional (rare) short lived (20mins) episodes of visual disturbance effecting whole field of vision. Blurring – no positive features – usually when working on computer. Gets headaches with some alcoholic beverages. 5/52 ago had an episode of “usual” visual disturbance followed by headache which has persisted. Tried variety of OTC analgesics – no help. H/a intensity waxes wanes no discernable pattern. Photophobic when intense. Has become irritable. Convinced has brain tumour. Examination normal including discs.

MR C Aged 44 3 months recurring episodes of severe peri/retro- orbital penetrating pain always on left. A least 1 episode per day. Some waken him at night when this occurs it is usually at a predictable time. Episodes last between 20 and 90 minutes. During the pain left eye reddens and waters profusely. Wanders around whimpering. Mr C is a police officer who is obliged to work shifts.

Mr H Aged years high headache burden. Periods of daily headache lasting several months. Reckons last headache free day was 2 years ago. Tried a wide range of analgesia – nothing helps although some respite with Solpadeine presently needing to take 8 tablets per day to get by. Amitriptyline prescribed 1 year ago but did not get on with it. Recurrent headaches as a child. Has always had to avoid alcohol because causes headache. Twin sister has migraine. Wants to be sorted out. In particular wants scan.

Mrs S Aged 67 Migraine with visual aura during teens. Low headache burden until mid 40’s then period (years) of high burden with periods of daily headache some very severe. Improved in late 50’s. Also tendency to headaches with orgasm since 20’s. From late 50’s rare h/a (apart from sex) but episodes of visual disturbance reminiscent of those as a teenager but not followed by h/a. (ziz-zag coloured effect appearing in right or left temporal field of vision enlarges migrates medially then fades – events last 25 mins.)

Mrs S Aged 67 – continued. 2 months ago caravanning with husband in Lake District. Decided to take a stroll before breakfast. Came across a sheep tangled in a wire fence. Able to release the animal after a bit of a tussle then developed exactly the same h/a as gets with sex. Went back to the caravan recalls entering the door but nothing for the next 2 hours. Husband in the van as entered he describes her as seeming very agitated and repeating over and over that she could not recall what she had been doing. Otherwise seemed very well and ate a hearty breakfast. After breakfast announced that she would like a shower. Took herself of to the ablutions block. Seemed calmer when she returned. Over the next few hours was able to start recalling some of the sequence of events but the period from arriving INSIDE the caravan until going for a shower remains blank.

Epidemiology Worldwide prevalence 47% WHO listed cause of major disability 3% of adults consult their GP with headache each year Female to male ratio 3:1 Accounts for 25% new referrals to neurology clinics Costs UK economy £2.25 billion annually

1. Migraine 1.1 Migraine without aura 1.2 Migraine with aura 1.3Ophthalmoplegic migraine 1.4 Retinal migraine 1.5 Childhood periodic syndromes that may be precursors to or associated with migraine 1.6 Complications of migraine 1.7 Migrainous disorder not fulfilling above criteria 2. Tension-type headache 2.1 Episodic tension-type headache 2.2 Chronic tension-type headache 2.3 Tension-type headache not fulfilling above criteria 3. Cluster headache and chronic paroxysmal hemicrania 3.1 Cluster headache 3.2 Chronic paroxysmal hemicrania 3.3 Cluster headache-like disorder not fulfilling above criteria 4. Miscellaneous headaches not associated with structural lesion 4.1 Idiopathic stabbing headache 4.2 External compression headache 4.3 Cold stimulus headache 4.4 Benign cough headache 4.5 Benign exertional headache 4.6 Headache associated with sexual activity 5. Headache associated with head trauma 5.1 Acute posttraumatic headache 5.2 Chronic posttraumatic headache 6. Headache associate with vascular disorders 6.1 Acute ischemic cerebrovascular disorder 6.2 Intracranial hematoma 6.3 Subarachnoid hemorrhage 6.4 Unruptured vascular malformation 6.5 Arteritis 6.6 Carotid or vertebral artery pain 6.7 Venous thrombosis 6.8 Arterial hypertension 6.9 Headache associated with other vascular disorder 7. Headache associated with nonvascular intracranial disorder 7.1 High CSF pressure 7.2 Low CSF pressure 7.3 Intracranial infection 7.4 Intracranial sarcoidosis and other noninfectious inflammatory diseases 7.5 Headache related to intrathecal injections 7.6 Intracranial neoplasm 7.7 Headache associated with other intracranial disorder 8. Headache associated with substances or their withdrawal 8.1 Headache induced by acute substance use or exposure 8.2 Headache induced by chronic substance use or exposure 8.3 Headache from substance withdrawal (acute use) 8.4 Headache from substance withdrawal (chronic use) 8.5 Headache associated with substances but with uncertain mechanism 9. Headache associated with noncephalic infection 9.1 Viral infection 9.2 Bacterial infection 9.3 Headache related to other infection 10. Headache associated with metabolic disorder 10.1 Hypoxia 10.2 Hypercapnia 10.3 Mixed hypoxia and hypercapnia 10.4 Hypoglycemia 10.5 Dialysis 10.6 Headache related to other metabolic abnormality 11. Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose sinuses, teeth, mouth, or other facial or cranial structures 11.1 Cranial bone 11.2 Neck 11.3 Eyes 11.4 Ears 11.5 Nose and sinuses 11.6 Teeth, jaws, and related structures 11.7 Temporomandibular joint disease 12. Cranial neuralgias, nerve trunk pain, and deafferentation pain 12.1 Persistent (in contrast to tic-like) pain of cranial nerve origin 12.2 Trigeminal neuralgia 12.3 Glossopharyngeal neuralgia 12.4 Nervous intermedius neuralgia 12.5 Superior laryngeal neuralgia 12.6 Occipital neuralgia 12.7 Central causes of head and facial pain other than tic douloureux 12.8 Facial pain not fulfilling criteria in groups 11 or Headache not classifiable International Headache Society Classification 1988

A EH Classification of Primary Headache Migraine Without aura With aura Tension-type Headache Episodic Chronic Cluster Headache and other trigeminal autonomic cephalalagias Coital Headache Exercise Headache Cough Headache Ice-pick Headache (Idiopathic Stabbing Headache) Hypnic Headache Analgesic Headache

All Headache is Migraine… Everybody gets Migraine…

Is the patient a migraineur?

Threshold?

IHS diagnostic criteria Migraine without aura* An idiopathic recurring headache with:A. At least 5 attacks fulfilling B-D B. Attacks last 4-72 hours C. At least 2 of the following - Unilateral location - Pulsating quality - Moderate or severe pain intensity - Aggravated by routine physical activity D. At least one of the following during an attack - Nausea and/or vomiting - Photophobia and phonophobia E. Not attributed to another disorder * In children, attacks may be shorter; also more commonly bilateral and GI disturbance is more prominent

Worth Asking About Balance Disturbance Dysequilibrium Vertigo Motion sickness Allodynia Including tenderness Hyperosmia Alcohol and headache

Is it a Tumour Nausea/vomiting 50% “Classic” 17 BUT > 3 months - unlikely >6 months – exceedingly unlikely

Red Flags New onset or change in headache in patients who are aged over 50 Thunderclap: rapid time to peak headache intensity (seconds to 5 mins) Focal neurological symptoms (eg limb weakness, aura 1 hr) Non-focal neurological symptoms (eg cognitive disturbance) ƒ Change in headache frequency, characteristics or associated symptomsƒ Abnormal neurological examination ƒ Headache that changes with posture ƒ Headache wakening the patient up (NB migraine is the most frequent cause of morning headache)ƒ Headache precipitated by physical exertion or valsalva manoeuvre (eg coughing, laughing, straining) Patients with risk factors for cerebral venous sinus thrombosisƒ Jaw claudication or visual disturbance ƒ Neck stiffness ƒ Fever ƒ New onset headache in a patient with a history of human immunodeficiency virus (HIV) infection New onset headache in a patient with a history of cancer

Treatment of Medication Overuse Headache Withdraw ? Cold turkey better that tapered. Indomethacin 50 tds or naproxen 250 tds (+ppi) for 14 days ?Diazepam 2mg tds Steroids Start neuro-modulator. Information. ( google Medication Overuse Headache)

Some Nuggets Pregnancy 70% improve Triptans not licenced but NICE suggests consider GON block useful (? Also TCS) Avoid NSAID in last trimester (Reye’s syndrome) Menstrual Migraine Pre-emptive Naproxen or frovatriptan. “Status” Course of regular Naproxen 500 bd 3-4 weeks GON block Prednisolone