1. Headaches - In Primary Care Dr M Banerjee GP Registrar Tadworth

2. Main Types Tension Headache Migraine Cluster Headache OR Secondary to underlying cause

3. History Duration Quality – Dull/stabbing/continuousAssociated features Triggers/relieving factors Use of drugs/complementary medicines and/or caffeine Psychological

4. Examination General- s/he looks unwell? Measure BP Neurological incl fundoscopy Head and neck

5. Secondary Headaches Intracranial lesion Meningitis Subarachnoid haemorrhage Acute close angle glaucoma Temporal arteritis

6. Red flag signs Increased ICP Focal neurological signs Constitutional signs Intensity- “worst headache of my life” Head injury New onset – age > 50 yrs

7. Cluster Headaches Comoner in males and smokers Once or twice every 24 hrs Pain free intervals Rapid onset of severe pain Usually unilateral and same sided Pain around eye – red eye & lacrimation

8. Migraine Visual aura -> throbbing Episodic severe Photophobia, nausea,vomiting Precipitating factors Symptom diaries

9. Tension Associated with stress & anxiety Usually worse at end of day Like a tight band around head

10. Cluster- management 100% O2 Ergotamine or triptan nasal spray Intranasal lidocaine Verapamil – prophylaxis May need neurologist referral

11. Migraine Acute- Analgesics Sumatriptan/ Rizatriptan Prophylaxis- Beta blockers TCA SSRI Ca channel blockers Pizotifen

12. Tension - management Reassure NSAIDS – avoid opioids Lifestyle modifications

13. Analgesic Rebound Daily headache Regular use – usually multiple Age 30-40; More in females (5:1) 20% of all chronic headaches Management: withdrawal of all analgesics Patient education/psychological support