Steve Elliot GPwSI Headache

Diagnosis of episodic headache Diagnosis of chronic headache Who to refer for scanning (Management of headache)

“Listen to the patient. He is telling you the diagnosis” Sir William Osler ( )

“The headache history has to be taken, not received” Professor Peter Goadsby

Why does it matter? Headache is not a diagnosis Clear diagnostic criteria Diagnosis before treatment Disease specific treatments

Guatama Buddha BC How to relieve suffering

8 questions - the way to end suffering in headache Location? Character? Severity? Aggravation by movement? Nausea/vomiting? Photophobia? Phonophobia? Duration?

IHS tension headache 2 of Bilateral Pressing./tightening/non pulsating quality Mild to moderate intensity Not aggravated by movement No more than 1 of Nausea/vomiting Phonphobia or photophobia Duration 30minutes to 7days

IHS migraine Need 2 out of: Unilateral Moderate-severe Throbbing Worse with movement Need 1 of Nausea and/or vomiting Photophobia and phonophobia Duration 4-72 hours

Cluster headache Side locked unilateral Peircing /drilling/grinding Very severe Not worse with movement Possibly nausea/vomiting Possibly unilateral photophobia Possible phonophobia minutes duration Autonomic symptoms Restless

Landmark study 1203 patients GP diagnosis of primary headache Headache diary for 3months Diaries analysed by blinded assessors Findings: 94% migraine or probable migraine 82% “tension type headache” had migraine

Agree or disagree? “... She complains of frequent headaches and she has missed a lot of time off work. She is having to look after her demented mother and is under considerable stress. The headaches are throbbing and associated with nausea and occasional vomiting. She has been to A+E on two occasions. Neurological examination is normal. I feel she is suffering from chronic tension headache.”

“Brain attack” Trigger – Dorsal pons Prodrome - Hypothalmus Aura – Cerebral cortex Peripheral sensitisation – Cranial vasculature Central sensitisation – Thalamus Nausea/vomiting- Area Postrema Autonomic symptoms – Parasympathetic system Neck pain – Sensitisation of C2/C3

Why me? Blame your parents Chemical imbalance Your brain is different Symptoms between attacks

Chronic headache 2-3% of population have headache on more days than don’t Half of above have medication overuse 2%/year migraine transforms to chronic Most preceded by episodic headache Co-mordidities anxiety,depression,obesity Difficult to manage

Causes chronic daily headache Primary headaches Chronic tension type headache Chronic migraine Chronic cluster headache Medication overuse headache New daily persistent headache Hemicrania continua

History in chronic headache Pattern Low grade all time? Low grade with exacerbations? Short lasting frequent? Stable or progressive? 8 questions Medication including OTC? Caffeine consumption? Exclude red flags

What not to miss Idiopathic intracranial hypertension Low pressure headache Giant cell arteritis Other secondary headache REMEMBER High pressure headache WORSE on lying flat Low pressure headache BETTER lying flat

Neuroimaging guidelines - a brief summary

What do we know? Incidence of brain tumour in general population is % per year 72% occur over age 50 In primary care risk of brain tumour with headache presentation is 0.09% If GP makes diagnosis of primary headache risk is 0.045% If GP cannot make diagnosis then risk is 0.15% and 0.28% if >50

What else do we know? Risk of brain tumour >1% if Papilloedema New epileptic seizure Significant alteration consciousness, memory loss, co-ordination, confusion History of cancer elsewhere Risk of lung cancer with haemoptysis 2.4% Risk of colon cancer with positive FOB 7%

SIGN guidelines “Neuroimaging is not indicated in patients with a clear history of migraine,without red features for potential secondary headache,and a normal neurological examination”

NICE, TWW and headache Headaches in whom a brain tumour is suspected Headache of recent onset accompanied by features suggestive of raised intracranial pressure eg Vomiting Drowsiness Posture related headache Pulse synchronous tinnitus Or by other focal or non-focal neurological symptoms eg blackout,change in memory or personality New, qualitatively different,unexplained headache that becomes progressively severe

Brain tumour headache 55% new or changed headache 5.1% “classic” raised ICP features 55.1% not classifiable by IHS 13.3% migraine 23.5% episodic tension type headache 40.8% occurred on 1-3 days per week 60.2% “pressing/tightening” 52% no trigger

And % headache as only symptom 74% brain tumours present within 3months 90% within 6 months Brain tumour headache may be similar to previous headache but more frequent/severe and associated with new symptoms

Red flags-SIGN guidelines New onset or change in patient over 50 New onset headache with history of cancer Abnormal neurological examination Headache that changes with posture Headache that wakes (most common migraine) Headache precipitated by physical exertion/Valsalva Non focal neurological symptoms eg cognitive disturbance) Patients with risk factors for CVST Jaw claudication or visual disturbance Neck stiffness Fever Change in headache frequency,characteristics or associated symptoms Thunderclap headache Headache that changes with posture New onset in patient with HIV Focal symptoms 60 Thunderclap heaadche

Paracetamol Aspirin or Ibuprofen Anti-emetic Domperidone or Metoclopramide Naproxen or Diclofenac Triptan Combination AVOID OPIOIDS Acute treatment migraine

Almotriptan Eletriptan Frovatriptan Naratriptan Rizatriptan Sumatriptan Zolmitriptan Which Triptan?

2 hour response Chance of relapse Adverse effects Cost Route of administration Which Triptan?

Tension type headache Amitriptyline/Nortriptyline (Mirtazapine) Migraine Amitriptyline/Nortriptyline Propranolol/Metoprolol Topiramate Sodium valproate or Gabapentin Prophylaxis of headache

“ The very first step towards success in any occupation is to become interested in it” Sir William Osler ( ) Canadian Physician