Rational brain imaging in primary care Richard Sylvester Consultant Neurologist Homerton University Hospital / NHNN Rational brain imaging in primary care

Why image the brain?

Brain imaging in primary care Vast majority requests are MRI for headache Where does MRI fit in the management of headache? What headaches present? Managing headache – pearls and pitfalls Developing an integrated pathway for headache

Headache – relieving symptoms is the aim Correct diagnosis – history/examination Effective management – knowledge Tests valuable only in minority of cases

Headaches – neurology OP Homerton neurology OPD (Oct – Dec 2012) 94/352 (27%) patients main complaint headache 96% primary (78% migraine, 13% TTH, 9% other) 45% analgesia overuse 1/3 previous imaging 1/3 imaged after clinic 85% discharged

Headaches – primary care >90% migraine >65% analgesia overuse When GP diagnosis is migraine – correct 98% If GP diagnosis is not migraine – incorrect 82% (Tepper et al, Headache 2004)

Diagnosing migraine Recurrent attacks Headache lasting 4–72 hours untreated At least two symptoms of: Throbbing/pulsating Unilateral Moderate or severe Worsened by movement/avoids routine physical activity And either: Nausea +/or vomiting Photophobia or phonophobia ICHD-2, 2004

Managing migraine Lifestyle – regular sleep, food/drink, reduce stress Abortive – high dose NSAID/domperidone - triptan/domperidone Prophylactic – propanalol, AEDs, amitriptylline Education – migraine trust website (Imaging – <1:2200 brain tumour)

Improving management Underdiagnosis Undermanaged NMC guidance for GPs Lack of all migrainous symptoms Absence of aura (>80%) Chronic headache – analgesia overuse Undermanaged Analgesia overuse propagated Abortives not used correctly Prophylactics - dose / length of treatment NMC guidance for GPs

Analgesia overuse headache >14 days month >2 days analgesic use per week Any analgesic Underlying primary headache Reduces efficacy of prophylactics Addiction pathway?

Other headaches Primary TTH – featureless, no analgesia overuse Cluster – 1-3 hrs, agitated TACS – rare Secondary ‘Red flags’

Why order a brain scan in someone with headache? Diagnose/exclude serious pathology Relieve anxiety (patient / doctor) Avoid referral to specialist (cost) Patient choice

What does imaging achieve in headache? It excludes serious pathology But headache alone is not a marker of structural pathology ‘red flag’ features are – need specialist input/imaging Thunderclap headache (peak intensity 1-5mins lasting >1hr) Fever/systemic illness Focal neurology / seizures Cognitive decline New onset daily headache in high risk group (>50yrs/cancer/immunosuppressed) Postural features suggestive low / high CSF pressure

What does imaging achieve in headache? It relieves anxiety Maybe in the short term but not for long RCT imaging vs none Outcome measure – anxiety scores / Is my headache caused by something serious ? Less anxiety at 3 months but not at one year (Howard et al JNNP 2005) Around 5% are not normal – more anxiety Chiari malformations Arachnoid/Pineal cysts Small meningiomas/aneurysms White matter lesions Pituatary abnormalities

What does imaging achieve in headache? Avoids specialist referral and reduces costs No cost benefit – minor reduction in referral rate (Wills et al, JNNP 2005) Open Access MRI with GP referral guidelines 169 scans in 12 months Incidentaloma rate: 3% No reduction in costs and minor reduction in referrals Imaging doesn’t diagnose and manage symptoms

What does imaging achieve in headache? Patients want scans Yes but they would prefer to get rid of their symptoms Normal scan may lead to trivialising symptoms

When do I use imaging? Red flags Triggered headache Head injury NODPH Rare phenotypes When I have little choice!

What imaging do I use? CT short wait, good for fractures / large lesions / less incidentalomas but radiation, poor resolution MRI – often need specific sequences Trauma – GE/SWI ?low CSF pressure – contrast TACS – pituitary imaging TN – brainstem sequences MRA/MRV – arterial/venous pathology

NMC guidelines for primary care

Neurology advice Urgent - Neurology SPR Homerton / RLH Routine - Email advice line huh-tr.NeurologyHomerton@nhs.net

Yes Yes Red flags? Urgent? A&E / medics / neuro SPR No Neurology OP Email advice service No Imaging Analgesia overuse? Stop analgesics success? Yes ?psychiatry input No No Imaging Yes Treatment Triggers Abortive Prophylaxis Neurology OP Email advice service Diagnostic pattern? Migraine? Yes Yes No No No Yes Others – cluster, TACS Triggered, NODPH Headache diary Review in 8/52 Diagnosis? Primary care management e.g. TTH, musculoskeletal No Neurology OP Email advice service Imaging

Developing an integrated headache pathway

Conclusions Always consider the aims and likely outcomes of brain imaging There are limited indications for brain imaging in headache Correct diagnosis and management are more reassuring than normal tests Its usually migraine and analgesia overuse!

Useful information Migraine trust http://www.migrainetrust.org/ National migraine centre http://www.migraineclinic.org.uk/ BASH http://www.bash.org.uk/