2. Headache

3. Headache affects 75% of population per year (45 million people) and 25% of Neurology OP referrals Daily headache affects 4% of population On any day 90,000 people are absent from work or school because of headache Migraine alone accounts for 20 million lost work or school days per year Cost of migraine to the economy in UK £1 billion per year

4. Most headaches are due to: Tension-type headache 70% Migraine 14%

5. Classification of headache 1. Primary headache ( from IHS 2003) (must have characteristic or benign features without abnormal neurological signs) 1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal autonomic cephalgias 4. Other headache not associated with structural lesion

6. Classification of headache 2. Secondary headache ( from IHS 2003) 5. Head or neck trauma 6. Cranial or cervical vascular disorders 7. Non-vascular intracranial disorders 8. Substances or their withdrawal 9. Infection 10. Disorder of homeostasis 11. Eye, ENT, orofacial, or cervical disorders 12. Psychiatric disorder 13. Cranial neuralgias and central causes of facial pain 14. Headache not classifiable

7. Migraine characteristics Attacks of headache lasting 4 to 72 hours Nausea and/or vomiting Intolerance of light Intolerance of noise Recurrent attacks Visual or neurological aura lasting 6 – 60 mins Consistent trigger

8. A few headache cases

9. Headache - Danger Signals First and worst headache Association with –loss of consciousness or collapses –non-migrainous visual disturbances or focal neurological signs –fever or rash Sudden headache with vomiting and/or loss of consciousness at onset Neck stiffness Jaw claudication (pts over 50)

10. Headache - Concerning features New onset headache after age 50 Genuinely increasing frequency and severity Waking patient from sleep Unresponsive to treatment Always on same side Following head trauma Precipitated by exertion New headache in patients: –On anticoagulants –With HIV or cancer

11. Diagnosis Careful history Examination –to exclude focal neurological signs or RIP –evidence of anxiety, tension or depression

12. Diagnosis 1 – History Careful attention to detail Recognition and assessment of each type of headache Details of onset, duration, pattern and progression. Night- time headache Associated features –Blackouts, collapses, jaw claudication, visual disturbances, incontinence Triggers, aggravating and relieving factors Effect on usual activities Treatments tried Lifestyle, work and home stress, anxieties Other relevant medical history Drugs, alcohol, medication

13. Diagnosis 2 - Examination Systemic disease, e.g. fever, BP, evidence of cancer To exclude focal neurological signs or RIP Visual field loss Papilloedema Cranial nerve palsies especially 3 rd and 6th Lateralised limb weakness Abnormal reflexes and extensor plantars Ataxia Abnormal gait Look for evidence of anxiety, tension or depression

14. Investigations None may be necessary Investigation of systemic disease if suspected ESR & CRP if GCA suspected Brain imaging –if structural lesion suspected –for reassurance (patient, relatives, doctor!)

15. Frishberg et al 1994 - The utility of neuroimaging in the evaluation of headache in patients with normal neurological examinations. Review of 23 studies1.

16. Headache Literature Elrington (1999) - 1000 headaches1 Ages8 - 87 Tension-type headache34% Migraine26% Psychiatric (mainly depression)12% Analgesic misuse 9%

17. Headache Literature Elrington (1999) - 1000 headaches2 Secondary headaches –Mass lesion1% (11) –SAH0.7% –Idiopathic intracranial hypertension0.2% –Giant cell arteritis0.1% Clinical features predictive of abnormal imaging –thunderclap headache –papilloedema –ataxia

18. AAN Guidelines on imaging in headache 1994 “In adult patients with recurrent headaches that have been defined as migraine including those with visual aura, with no recent change in pattern, no history of seizures and no other focal neurological signs and symptoms, the routine use of neuroimaging is not warranted. In patients with atypical headache patterns, a history of seizures or focal neurological signs or symptoms, CT or MRI may be indicated.”

19. Indications for referral? 1. Where specialist diagnosis is required 2. Clincal features suggest significant or serious neurological disease 3. Failure to respond to appropriate adequate treatment 4. Patient at high risk of serious disease 5. Reassurance

20. Indications for referral 1. Where specialist diagnosis is required Unclear clinical features Imaging required 2. Clincal features suggest significant or serious neurological disease 1.Progressive or sinister headache symptoms 2.Associated neurological symptoms (e.g. seizures, blackouts, collapses) 3.Abnormal neurological signs 3. Failure to respond to appropriate adequate treatment 4. Patient at higher risk of serious disease 1.Cancer patients 2.New headache in older patients 5. ?reassurance

21. Where to refer? A&E/ACUHeadache ClinicNeurology Clinic Very short history suggesting catastrophic or acute life-threatening disease. e.g meningitis, SAH, ICH, encephalitis Diagnosis and advice on management in primary care of patients whose main problem is headache Diagnosis and management of patients with primarily neurological diseases who cannot be managed in primary care

22. Headache Clinic

23. Headache Clinic 581 patients 34 (6%)Analgesic misuse 12 (2%)Non-classifiable 7 (1%)Face, Neck, Ears, Neuralgias 5 (1%)*Non-vascular intracranial disorders (incl tumours) 5 (1%)Vascular 5 (1%)Trauma 14 (2%)Other non-structural 16 (3%)Cluster 229 (39%)Tension-type 199 (34%) Migraine

24. Headache Clinic 581 patients Non-vascular intracranial disorders Intracranial tumour 1 BIH 2 Aqueduct stenosis 1 Other 1

25. What is the outcome of investigation? Headache Clinic 581 patients CT 239 Relevant abnormality 2

26. Management of Tension-Type Headache and Migraine

27. Management Accurate diagnosis Clear explanation Discuss environmental factors General advice –diet, coffee, alcohol, lifestyle, use of analgesics –Stress and anxiety management –relaxation Specific treatment

28. Management of Tension-type headache Lifestyle issues –work-home-leisure balance –exercise –sleep Physical measures –relaxation –physio –self-help Drugs –limited simple analgesics –amitriptyline –SSRIs –others

29. “Wolcott’s instant pain annihilator”

30. Acute attacks of Migraine Early analgesics –Aspirin 600-900mg –Ibuprofen 400mg –Paracetamol 1G Analgesics plus antiemetics –Metoclopramide –Buccastem Triptans –Rizatriptan 10mg –Almotriptan 121.5mg –Eletriptan 40-80mg

31. Prevention of Migraine Consider if 2 or more attacks per month –Beta-blockers –Pizotifen –Amitriptyline –Venlafaxine –Valproate –Topiramate –Gabapentin

32. Headache Guidelines www.bash.org.uk www.sign.ac.uk