1. Andrew Graham Consultant Neurologist June 22 2016
Headache
Andrew Graham
Consultant Neurologist
June

2. “The patient with a headache often finds himself a medical orphan
“The patient with a headache often finds himself a medical orphan. He is fortunate indeed if his headache is transient, for otherwise he may find himself on an excursion to the ophthalmologist, otolaryngologist, neurologist, dentist, psychiatrist, chiropractor, and the latest health spa. He is x rayed, fitted with glasses, analysed, massaged, relieved of his turbinates and teeth, and too often emerges with his headache intact” RC Packard 1979

3. Headaches Primary care consultations Neurology OPD 30%
6.4 /100 women
2.5/100 men
Neurology OPD 30%
Life time prevalence of headache >90%

4. Headache Can I classify this headache? Do I need to investigate?
What does the patient want?
Is treatment appropriate? And if so what is the most sensible approach?

5. Can I classify this headache?
History
Periodicity
Associated features
Behaviour during headache
Family history
Current medication
Social situation/stressors

6. Can I classify this headache?
Primary headache
Secondary headache
Migraine
Tension type headache
Cluster headache and other trigeminal autonomic cephalalgias
Other primary headaches
Medication overuse headache
GCA
Acute narrow angle glaucoma
Lesions and structural causes
Raised intracranial pressure
Low pressure headache
Chronic meningoencephalitis
Post brain insult headache

7. Primary headache syndromes
Migraine (with or without aura)
Tension type
Cluster and other trigeminal autonomic cephalalgias
Other primary headaches

8. 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

9. Tension type headache Featureless headache Bilateral
Tightening quality
Mild to moderate severity
Absence of features of migraine

10. Cluster headache Severe unilateral pain Rapid onset
Autonomic features on same side
15mins to 3 hours duration
1-8 attacks a day
Restless during an attack
Striking circadian rhythm

11. Other primary headache syndromes
Hemicrania continua
Primary stabbing headache
Primary cough headache
Primary exertional headache
Primary headache associated with sexual activity
Primary thunderclap headache
Hypnic headache

12. Secondary headache Need to consider Raised intracranial pressure
Low pressure headache
Chronic meningoencephalitis
Post brain insult headache
Giant cell arteritis
Glaucoma
Cerviogenic
Disorders of eyes/ears/nose/sinuses/teeth
Depression
Vascular disorders

13. Secondary headache Need to consider Raised intracranial pressure
Low pressure headache
Chronic meningoencephalitis
Post brain insult headache
Giant cell arteritis
Glaucoma
Cerviogenic
Disorders of eyes/ears/nose/sinuses/teeth
Depression
Vascular disorders

14. 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

15. General Examination Blood pressure Neck examination Temporal pulses
Posture
Range of movement
Muscle tone
Muscle tenderness
Temporal pulses

16. Neurological Examination
Fundoscopy
Cranial nerves
Tone, power, reflexes and coordination in all four limbs
Plantars
Gait including heel toe walking

17. Do I need to investigate?
Headache syndromes where a structural explanation is plausible
Localising neurological symptoms/signs not explained by aura
Constitutional or systemic symptoms/signs
Recent diagnosis/treatment for cancer
Unclassifiable headaches
New daily persistent headache

18. Investigations Blood tests: ESR, TFTs Doing a scan
CT radiation risk and best for acute pathology
MRI no radiation but risk of incidental finding can be up to 1 in 10

19. Scanning
Prospective study new headache >4 weeks significant intracranial abnormality in:
Migraine %
Tension type headache 0.8%
Cluster headache 5%
Not clearly defined 3.7%

20. What does the patient want?
Explanation
Reassurance
Treatment

21. Is treatment appropriate?
Headache diary
Avoid opiates

22. Medication overuse headache
Most common culprits opiates-(codeine) and triptans
Any acute symptomatic treatment can cause it
Patients often under report what they are taking
Need to stop all medication for 7-10 days
Then consider preventative treatment

23. Management of tension type headache
Lifestyle issues
work-home-leisure balance
exercise
sleep
Physical measures
relaxation
massage
self-help
Drugs
limited simple analgesics
Amitriptyline
SSRIs

24. Acute migraine treatment
Early analgesics
Aspirin mg
Ibuprofen 400mg
Paracetamol 1G
Analgesics plus antiemetics
Metoclopramide
Buccastem
Triptans
Rizatriptan 10mg
Almotriptan 121.5mg
Eletriptan 40-80mg

25. Prevention of migraine
Consider if 2 or more attacks per month
Beta-blockers- propranolol
Topiramate
Gabapentin
Amitriptyline
Valproate
Pizotifen

26. Cluster headache Acute- oxygen or triptan (subcut or nasal)
Prophylaxis -Verapampil

27. Review Classification of headaches Investigations and scanning
Primary headaches
Secondary headache disorders
Investigations and scanning
Patient expectations
A sensible approach to treatment

28. 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

29. Further reading
SIGN diagnosis and management of headache in adults: a clinical guideline
NICE guideline CG150 Headaches: diagnosis and management of headaches in young people and adults