Presentation on theme: "‘A ubiquitous part of being human’ (Taylor et. al. BJGP 2014)"— Presentation transcript:
‘A ubiquitous part of being human’ (Taylor et. al. BJGP 2014)
To improve GPST knowledge regarding diagnosis and management of headaches, focussing on ‘Primary’ headaches; tension, cluster, migraine and also medication overuse headache (MOH).
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.
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)
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
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
‘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
Jane, 42, accountant.
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
Felicity, 25, junior doctor.
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)
Scott, 35, teacher.
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.
Claire, 55, museum curator
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
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
1. 5-HT1 agonist 2. Treatment 3. Timing 4. Three 5. Take 2 nd dose 6. Trouble
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.
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
APPGPHD (All Party Parliamentary Group on Primary Headache Disorders), Headache Service in England. A report of the All Party Parliamentary Group on Primary Headache Disorders Published by the House of Commons. Available from: BASH, 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, Migraine: patient experience, understanding of pathology, therapies. Video module available from: therapies.html?moduleId= &searchTerm=%E2%80%9Cmigraine%E2%80%9D&page=1&locale=en_GB Cochrane Pain, Palliative and Supportive Care Group, Acupuncture for tension-type headache. Published Online: January 2009 Assessed as up-to-date: 14 APR 2008 Available from: Frich, J et al 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, Available from; Headache Classification Subcommittee of the International Headache Society, The International Classification of Headache Disorders 2 nd Edition. Cephalalgia 24:1 Available from: Kernick, D. et al What happens to new onset headache presented to Primary Care? A case cohort study using electronic primary care records. Cephalalgia. 28: NICE, NICE Quality Standards[QS42]: Headaches in Adults and Young People. Published online August Available from: Longmore, Murray. et al. Oxford Handbook of Clinical Medicine 9 th edn. (p ). Oxford University Press 2014 Taylor, T. Et al Headache: Two view on the right approach in General Practice. British Journal of General Practice 64 (626) Available from: