1. Headaches
Feedback from BASH
3rd Nov 2017

2. DemogrAphics Problem for 40% of adult population in UK
Migraine affects 15% of adult population
woman to men 3:1
attacks/day
mostly in productive years
people off/every day
costing economy 1.5 billion/annum
Cluster headaches less common-0.05% prevalence
Medication overuse headaches in 2 % of adults
most primary headache presentations are related to migraine(90%)

3. International Classification of Headache Disorders
Primary headaches
Migraine
Tension type headaches
Cluster headaches
Secondary headaches
Attributed to head/neck trauma
vascular disorders
non vascular disorders
withdrawal
infection
facial pain
psychiatry
Neuralgias
trigeminal neuralgias

4. History taking
Important
Time Questions
Character Questions
Cause Questions
Response Questions
Health between attacks Questions

5. Migraine
Recurrent moderate to severe headaches
Lasting 1-3 days
Associated with gastrointestinal symptoms
Activities limited during attack
Prefer dark/quiet
Free of symptoms between attacks
Chronic migraine rare-more than 15 days a month

6. Tension type headaches
Attack -like episodes
Low frequency
Lasting several hours
Usually unilateral,can be generalized
Pressure/tightness/pulsating
Disabling
No associated symptoms
Associated with stress/functional cervical musculoskeletal abnormalities

7. Cluster headaches Mostly in men Usually in their 20’s Often smokers
Bouts of 6-12 weeks once/year
Intense pain
Mainly focused on one eye
Often at the same time (after been asleep for 1-2 hours)
Autonomic features
unilateral conjunctival injection
lacrimation
blocked nose
ptosis-Horners
Alcohol/smells /sleep /exercise can trigger headaches

8. Medication overuse headaches
1 in 50 adults suffer from MOH
Woman to men 5:1
Primary medications
Triptans
combination analgesia containing barbiturates/
caffeine/codeine
Worst in morning
Increased by exercise
Over time episodes become more frequent
Using medication more than 3 month and more than 15 days/month

9. Differential Diagnosis
Often structural neck problems-aggreviated by movement
Should not be attributed to sinus disease unless having other symptoms
Should not be attributed to ear/TMJ/Teeth unless having other symptoms

10. Concerning features New headaches Thunderclap headaches
During time on combined oral contraceptive medication
Older than 50 and new headaches
Persistent morning headaches with nausea
Progressive headaches
History of cancer
HIV

11. Features of high pressure headaches
Wakes patient up
Cough headaches
Pulsatile tinnitus
Seizures
Cognitive change
Papilloedema

12. ED presentations Migraine 55% Tension type headaches 25%
Cluster headaches 7%
Secondary headaches 13%
? scan/not to scan-?CT/?MRI
No big impact on survival rates by early scanning

13. Examination History! Optic fundi BP-but rarely the cause
Neck/TMJ examination
Only 0.9% of consecutive headache patient without neurological symptoms
had significant pathology

14. Serious causes of headaches
Intracranial tumors
produces rarely headaches until quiet large
only 3-4% present as headaches (1 in a million) of population per year
exception are frontal lobe-presenting with personality changes
Meningitis
SAH
Giant Cell Arteritis
Primary angle closure glaucoma
IHH
CO poisoning

15. Treatment Migraine in pregnancy Paracetamol
Aspirin/NSAIDS-except third Trimester
Triptans-Sumatriptan appears safe
Metoclopramide
Breast feeding
Ibuprofen/diclofenac
Sumatriptan-no breastfeeding for 12 hours
Cluster headaches
Oxygen
Sumatriptan nasal 3/day
Verapamil up to 960 mg/day

16. Idiopathic intracranial hypertension
Obese women in childbearing age
Presenting with papilloedema
normal neuro examination
normal neuro imaging
LP pressure more than 25
but elevated pressure only makes diagnosis
if also other symptoms present
also if LP relieves symptoms-not diagnostic !
Papilloedema
important not to miss
OCT scanning-discuss with ophthalmology
has not to be symmetrical
MRI
empty Sella possible feature of IHH
presenting with visual loss
needs urgent surgical shunt
last resort-high revision rates
always consider
venous sinus thrombosis
Anaemia
Tetracycline
Nitrofurantoin

17. ED presentation with IIH
? papilloedema-?need OCT
Check bloods regarding infection/anaemia
? blocked shunt
Consider
Migraine
Medication overuse headaches
low pressure headaches
Rarely Ct head useful