1. 02/05/20151 HEADACHES; When to seek advice? DR FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST

2. LEARNING OUTCOME Headaches requiring urgent advice from GP Headaches requiring expertise from a Neurologist/Headache specialist Uncommon but potentially serious headaches Common Headache Disorders in the population

4. 02/05/20154 HEADACHES One of the commonest symptom Account for 30% GP and 50% Neurology Referrals 95% of the population at some stage experience headaches 15-19% of Acute Medical Admissions (1), 55% of Neurology in A & E (2) 1. Weatherall M., J RCP Edinb 2006; 36: 196-200 2. Craig J., Patterson V., Roche L., JamisonJ., Accident and Emergency Neurology: time for a reappraisal? Health Trends, 1997, 29, 89-91

6. 02/05/20156 HEADACHES REQUIRING URGENT GP CONSULTATION Sudden onset of worst ever headache Headaches with fever/rash drowsiness Rapid progression of new onset headache New headache starting after age 50 Change in characteristics or pattern of longstanding headache

7. HEADACHES REQUIRING SPECIALISTS’ INPUT Difficulty in establishing a diagnosis Migraine/Tension headache refractory to treatment Headaches requiring frequent analgesia Short lasting headaches/symptoms suggesting Cluster Headaches

8. 02/05/20158 PRIMARY VS SECONDARY HEADACHES Primary Headaches have no underlying cause and are mostly harmless and potentially treatable e.g. Migraine, Tension Headaches Primary Headaches have no underlying cause and are mostly harmless and potentially treatable e.g. Migraine, Tension Headaches Secondary Headaches have an underlying cause and are still potentially treatable Secondary Headaches have an underlying cause and are still potentially treatable

9. 02/05/20159 SECONDARY HEADACHES NON SERIOUS (Common ) NON SERIOUS (Common ) 1. Referred Headaches 2. Medication Overuse 3. Minor Head Injury

10. 02/05/201510 Causes of Referred Headaches Eyes – Errors of Refraction Eyes – Errors of Refraction ENT – Sinuses ENT – Sinuses Teeth – Peridontal Disease Teeth – Peridontal Disease Jaw – Temporomandibular dysfunction Jaw – Temporomandibular dysfunction Neck – Degenerative Spinal Disease Neck – Degenerative Spinal Disease

11. 02/05/201511 SECONDARY HEADACHES Serious (< 1%) Serious (< 1%) 1. Brain Tumours 2. Brain Haemorrhage 3. Meningitis/Encephalitis 4. Temporal Arteritis

12. 02/05/201512 PRIMARY HEADACHES Virtually All of them are Benign or Harmless Virtually All of them are Benign or Harmless Tension Headache is the commonest Tension Headache is the commonest Migraine is the second most common Migraine is the second most common Cluster Headaches and Neuralgias are uncommon but treatable Cluster Headaches and Neuralgias are uncommon but treatable

13. 02/05/201513 PRIMARY HEADACHES Tension Headaches (60-75%) Tension Headaches (60-75%) Migraines (15-25%) Migraines (15-25%) Others like Cluster Headaches, Neuralgia(<1%) Others like Cluster Headaches, Neuralgia(<1%)

14. 02/05/201514 SHORT VS LONG DURATION HEADACHES < 4 HOURS Ice Pick Headaches Cluster Headaches Neuralgias < 4 HOURS Ice Pick Headaches Cluster Headaches Neuralgias > 4 HOURS MIGRAINES TENSION HEADACHES MEDICATION OVERUSE HA > 4 HOURS MIGRAINES TENSION HEADACHES MEDICATION OVERUSE HA

15. 02/05/201515 How to Recognise Tension Headaches ? Pressure, Like a band, Head in a vice Pressure, Like a band, Head in a vice Usually all over the head Usually all over the head Sickness and Sensitivity to light and sound is fairly uncommon Sickness and Sensitivity to light and sound is fairly uncommon Stressful event/ Worrying about tumour Stressful event/ Worrying about tumour

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17. 02/05/201517 How to recognise Migraine ? Pulsating/Throbbing Pulsating/Throbbing Unilateral/Bilateral frontal/temporal Unilateral/Bilateral frontal/temporal Sickness and Sensitivity to light/sound/smell Sickness and Sensitivity to light/sound/smell Exacerbation with Physical activity Exacerbation with Physical activity Lasting more than 4 hours unless a good analgesic response. Lasting more than 4 hours unless a good analgesic response.

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19. 02/05/201519 TYPES OF MIGRAINE Common Migraine (Migraine without Aura) Common Migraine (Migraine without Aura) Classical Migraine (Migraine with Aura) Classical Migraine (Migraine with Aura) Migrainous Aura without Headaches Migrainous Aura without Headaches

20. 02/05/201520 How to Recognise a Migraine Aura ? Symptoms similar to a Transient Ischaemic Attack (MINI STROKE) Symptoms similar to a Transient Ischaemic Attack (MINI STROKE) Young age Young age Family History Family History Gradual progression of symptoms Gradual progression of symptoms Visual aura is commonest Visual aura is commonest

21. 02/05/201521 Visual Aura

22. 02/05/201522Scotoma

23. 02/05/201523 Visual Blurring

24. 02/05/201524 How to recognise Cluster Headaches ? More common in Men (M:F = 6:1) More common in Men (M:F = 6:1) More common in Smokers (90%) More common in Smokers (90%) Excruciating Headaches Excruciating Headaches 2-8 times per day each lasting 30-120 minutes 2-8 times per day each lasting 30-120 minutes Strictly unilateral/frontal/around eyeball Strictly unilateral/frontal/around eyeball Runny Blood Shot and droopy eye Runny Blood Shot and droopy eye Early morning attacks Early morning attacks

25. 02/05/201525 Cluster Headaches

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28. 02/05/201528 How to Recognise Medication Overuse Headaches ? Usually cause Round the Clock Daily headaches (Chronic Daily Headaches) Usually cause Round the Clock Daily headaches (Chronic Daily Headaches) Consumption of Painkillers for 15 or more days per month for more than 3 months Consumption of Painkillers for 15 or more days per month for more than 3 months More common with opiate analgesics, ergotamine and triptans More common with opiate analgesics, ergotamine and triptans

29. Chronic Migraine Headache for 15 days or more 8 days of migraine headaches With or without medication overuse Triggers are more common Most disabling of all headache disorder excluding cluster headache Usually without aura

30. 02/05/201530 How to recognise Neuralgias ? Attacks are very short i.e., few seconds Attacks are very short i.e., few seconds Trigeminal Neuralgia is the commonest Trigeminal Neuralgia is the commonest Attacks precipitated by chewing, brushing, shaving and speaking Attacks precipitated by chewing, brushing, shaving and speaking Mainly over cheeks / Jaw not around eyes Mainly over cheeks / Jaw not around eyes

31. 02/05/201531 Standard abortive therapy Standard abortive therapy Migraine; How to manage?

32. Identify any obvious triggers Infrequent attacks Acute treatment only Frequent attacks Acute and Preventative treatments

34. ROLE OF SPECIALIST CLINICS Establish or Re-confirm the Diagnosis Investigations if necessary Appraise the available treatments for an individual Identify the best possible acute and/or preventative treatment/alternatives Provide information on treatment outcomes Advise on new treatments Provide support through Specialist Nurse

35. I WANNA TRY BOTOX NEXT

36. BOTOX Licensed for Chronic Migraine Not available on the NHS yet Multiple small injections in head muscles Effect last for 4-6 months Currently clinicians being trained to do it Case is being made for NHS Rx

37. THANK YOU ANY QUESTIONS 02/05/201537