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‘A ubiquitous part of being human’ (Taylor et. al. BJGP 2014)

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Presentation on theme: "‘A ubiquitous part of being human’ (Taylor et. al. BJGP 2014)"— Presentation transcript:

1 ‘A ubiquitous part of being human’ (Taylor et. al. BJGP 2014)

2  To improve GPST knowledge regarding diagnosis and management of headaches, focussing on ‘Primary’ headaches; tension, cluster, migraine and also medication overuse headache (MOH).

3 1. To appreciate the scale of the problem 2. To be able to take a headache history 3. To be alert to ‘red flags’ 4. To be able to do a 3 minute neuro exam to exclude serious underlying pathology 5. To be aware of the key point in Ix/Mx of primary headache.

4  Headache = sensation of pain felt within the skull.  Annual prevalence = 80%  4% of GP consultations and 33% of neurology OP appointments.  Primary headache costs the UK £5-7 billion a year  England has a ratio of 1 neurologist to 117,000 of the population. This is up to 10 x lower than elsewhere in Europe. (RCGP curriculum and APPGPHD, 2014)


6 Worsening headache + fever Sudden onset, max intensity in 5 mins – Worst ever New neurological deficit New cognitive dysfunction Personality change Impaired Consciousness Recent head trauma (within 3 mo) Triggered by cough, valsalva, sneeze Triggered by exercise Orthostatic Headache ? GCA Visual Disturbance/Jaw claudication/tender scalp ? Acute closed angle glaucoma – painful red eye, haloes, dilated pupil Immunocompromised Vomiting + no obvious cause History of malignancy that metastases to brain or any if <20 Substantial change in pattern of normal headaches

7 1. Tension 2. Migraine 3. Cluster + other trigeminal autonomic cephalalgias 4. Other - eg. hypnic headaches Primary Headache 1. Post-traumatic – ICB, + also whiplash 2. Vascular – eg. Haemorrhagic stroke/ Temp arteritis 3. Non-vascular – eg. SOL, BIH 4. Infectious – eg. Meningitis, sinusitis 5. Disorders of Homeostasis – eg. phaeochromocytoma, PET, hypoglycaemic headache. 6. Headache attributable to disorder of neck, eyes, ears, teeth, sinuses eg. Acute glaucoma, TMJ, refractive error 7. Psychiatric – somatisation disorder, psychotic disorder 8. Attributable to a substance or its withdrawal – eg. MOH Secondary Headache

8  ‘Perform and understand the limitations of a screening neurological examination’ –RCGP curriculum  General appearance, temp.  Blood pressure – patients will expect this  3 minute neuro exam

9  Jane, 42, accountant.

10 Tension headache  ‘Featureless’  Episodic 15d  Associated w/ stress  NICE, 2012: 1. Give a positive diagnosis 2. Do not offer neuro-imaging just for reassurance 3. Do not offer codeine – offer aspirin/paracetamol/NSAIDS 4. Acupuncture may help (Cochrane, 2009) 5. Headache diary


12  Felicity, 25, junior doctor.

13 Medication Overuse Headache Headache occuring >15 days/month with associated use of:  Simple analgesics, >15 days/month  Ergot/codeine/triptans > 10 days/month  Often secondary to TTH/Migraine NICE, 2012/BASH, 2010: 1. Explanation – paradoxical effect of analgesia 2. Abruptly stop all medication for at least 1 month – may need to plan sick leave 3. Close follow-up and r/v in 4-8 weeks. Address underlying disorder 4. More common with ‘low acceptance of pain’ and ‘problem solving mode’ – motivational interviewing may be necessary (Frich et al. 2014)

14 Scott, 35, teacher.

15 Cluster Headache  Possibly due to temp artery hypersensitivity to 5HT.  ♂: ♀ 5:1 and smokers, 3 rd /4 th decade  Headaches are stereotypical and occur in bouts of 6-12wks – once every year/ 2 years NICE, 2012: 1. Acutely – give 12l oxygen via NRB for 15 mins + nasal/subcut triptan eg. Zolmitriptan 5mg nasally (Simple analgesics won’t work) 2. DO discuss with Neurology. Some neurologists will want imaging w/ 1 st attack 3. Home oxygen - HOOF form 4. Prophylactic Medicine – best evidence for verapamil. Needs an ECG beforehand to check for AV block. Discuss with neuro if unfamiliar with this use. Specialist may also initiate lithium or methysergide.

16  Claire, 55, museum curator

17 Migraine  Moderate/Severe headaches, which impair routine activity, tend to be unilateral and throbbing, often associated with photo/phono-phobia, N&V.  Affects 10% population, twice as common in women  30% occur with aura (visual/somatosensory/speech/motor), the rest without.  Cause: Neurovascular disorder. Hyperexcitable brain compared to non migraine sufferers and pain is referred inappropriately from the nociceptors in the meninges and intracerebral blood vessels. (BMJ learning, 2014)  Triggers (50%) (OHCM, 2014): C H O C O L A T E

18 NICE 2012: Acutely:  Offer an oral triptan + ibuprofen 600mg/paracetamol  Consider antiemetic even if no nausea (eg. Domperidone 10mg /metaclopramide 10mg)  Do not use opioids  Do not refer for neuroimaging for reassurance  DO refer if prolonged aura /motor symptoms or ? Stroke/TIA Prophylaxis:  Discuss trigger avoidance and preferences, but can try propranolol/ topiramate (note: teratogenic) Second line, try acupuncture, gabapentin.  Riboflavin (400mg od ) may be effective – expensive. Chronic Migraine >15 d/mo for 3 mo and not overusing medication:  Botox may help Menstrual Migraine:  For predictable menstrual-related migraine consider treatment with triptain on the days migraine is expected.  NOTE: If female patient has migraine with aura avoid COCP – ischaemic stroke risk

19 1. 5-HT1 agonist 2. Treatment 3. Timing 4. Three 5. Take 2 nd dose 6. Trouble

20  Rare - disproportionately affect younger pts  Kernick et al., 2008: 0.045% risk at 1 year risk of malignant brain tumour in those diagnosed with primary headache in GP.  Tumours rarely cause headache until quite large (except for pituitary tumours) at which point likely to be other signs/sympts of raised ICP (seizures/papilloedema)  NICE is clear that neuroimaging should not be offered for reassurance if clear Hx migraine/tension headaches  5% MRI heads bring up incidental findings, anxiety and F/U needed. Insurance implications.

21  Headache is common  History and Examination is crucial to exclude potentially serious causes  Much of the burden of primary headache management is achievable in GP, with appropriate access to secondary care as necessary

22 Any questions/cases?

23  APPGPHD (All Party Parliamentary Group on Primary Headache Disorders), 2014. Headache Service in England. A report of the All Party Parliamentary Group on Primary Headache Disorders 2014. Published by the House of Commons. Available from:  BASH, 2010. Guidelines for all Healthcare Professionals in the Diagnosis and ManAgement of Migraine, Tension Type Headache, Cluster Headache and Medication Overuse Headache. 3 rd edition (1 st revision 2010). Available from:  BMJ Learning, 2014. Migraine: patient experience, understanding of pathology, therapies. Video module available from: therapies.html?moduleId=10021852&searchTerm=%E2%80%9Cmigraine%E2%80%9D&page=1&locale=en_GB  Cochrane Pain, Palliative and Supportive Care Group, 2009. Acupuncture for tension-type headache. Published Online: January 2009 Assessed as up-to-date: 14 APR 2008 Available from:  Frich, J et al. 2014. e GP’s experiences with brief intervention for medication-overuse headache: a qualitative study in general practice British Journal of General Practice 64(626) e525-e531; Available from:  GP notebook, 2014. Available from;  Headache Classification Subcommittee of the International Headache Society, 2004. The International Classification of Headache Disorders 2 nd Edition. Cephalalgia 24:1 Available from:  Kernick, D. et al. 2008. What happens to new onset headache presented to Primary Care? A case cohort study using electronic primary care records. Cephalalgia. 28:118-1195  NICE, 2013. NICE Quality Standards[QS42]: Headaches in Adults and Young People. Published online August 2013. Available from:  Longmore, Murray. et al. Oxford Handbook of Clinical Medicine 9 th edn. (p460-463). Oxford University Press 2014  Taylor, T. Et al. 2014. Headache: Two view on the right approach in General Practice. British Journal of General Practice 64 (626) 475-476 Available from:

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