1. HEADACHE Dr Nick Pendleton March 2015

2. Headache Tension Type Headache Cranial Nerve Examination Migraine Migraine Treatment Medication Overuse Headache Headache Red Flags Sinusitis Headache Raised ICP Headache Acute Severe Headache

3. Small Group Work Tension Type Headache Cranial Nerve Examination Migraine Migraine Treatment Medication Overuse Headache Headache Red Flags Sinusitis Headache Raised ICP Headache Acute Severe Headache

4. NICE GUIDELINE CG150 Diagnosis and Management of Headaches in Young People and Adults https://www.nice.org.uk/guidance/cg150

5. (A)At least 10 episodes fulfilling the criteria B-D: (B) Headache lasting from 30 minutes to 7 days (C) Headache has at least two of the following characteristics: Bilateral location Pressing/tightening (non-pulsating) quality Mild or moderate intensity Not aggravated by routine physical activity such as walking or climbing stairs (D) Both of the following: No nausea or vomiting (anorexia may occur) No more than one episode of photophobia or phonophobia (E) Not attributable to another disorder

6. Patient with Tension-Type Headache indicating location of his headache pain. Loder E, Rizzoli P BMJ 2008;336:88-92 ©2008 by British Medical Journal Publishing Group

7. Infrequent episodic tension-type headache Diagnosed if headaches meeting the above criteria occur <1 day a month (<12 days a year) on average Frequent episodic tension-type headache Diagnosed if headaches occur >1 and 12 and <180 days a year). Chronic tension-type headache Diagnosed if headaches occur ≥15 days a month (180 or more days a year).

8. RED FLAGS Onset of new or different headache Nausea or vomiting Worst headache ever experienced Progressive visual or neurological changes Paralysis Weakness, ataxia or loss of co- ordination Drowsiness, confusion, memory impairment or loss of consciousness Onset of headache after age of 50 years

9. More RED FLAGS Symptoms/Signs of Papilloedema Stiff neck Onset of headache with exertion, sexual activity or coughing Systemic illness Numbness Asymmetry of pupillary response Sensory loss Signs of meningeal irritation

10. Link to Article about Red Flags http://www.gponline.com/red-flag- symptoms-headaches/neurology/headache- migraine/article/1332134 http://www.gponline.com/red-flag- symptoms-headaches/neurology/headache- migraine/article/1332134

14. MIGRAINE

16. Migraine Repeated attacks of headache lasting 4–72 hours that have these features : A: Normal physical examination B: No other reasonable cause for the headache C: At least two of: Unilateral pain Throbbing pain, Aggravation of pain by movement, Moderate or severe intensity of pain D: At least one of Nausea or Vomiting Photophobia and phonophobia

17. MIGRAINE WITH AURA 20–30% experience migraine with aura Focal neurological phenomena that precede the attack Appear gradually over 5 to 20 minutes and generally last fewer than 60 minutes Headache phase usually begins within 60 minutes of the end of the aura phase.

18. AURA Common aura symptoms include: Visual disturbances (such as flashing/flickering lights, zigzag lines and even temporary blindness) Numbness, tingling sensations and slurred speech. Other aura symptoms include a stiff neck, weakness on one side, partial paralysis, confusion or fainting

19. Migraine, Stroke and the OCP Patients who have Migraine with Aura are at increased risk of ischaemic stroke Giving these patients an OCP increases this risk significantly + Hypertension + Smoking + age > 35

20. Some figures: In Women under 35: those who do not have migraine and do not take the pill (i.e. the background risk): 1.3 per 100,000 women per year are at risk of stroke those who have migraine without aura but don’t take the pill: 4 per 100,000 women per year at risk of stroke those who have migraine with aura but don’t take the pill: 8 per 100,000 women per year are at risk of stroke those who don’t have migraine and take the pill: 5 per 100,000 women per year at risk of stroke those who have migraine with aura and take the pill: 28 per 100,000 women per year at risk of stroke those who have migraine without aura and take the pill: 14 per 100,000 women per year are a risk of stroke http://www.migrainetrust.org/factsheet-stroke-and-migraine-10891

21. Treatments for Migraine Triptans, selective 5-HT 1B/1D receptor agonists –various formulations & types Ergot derivatives (older treatment, not commonly used) Antiemetics & nsaids Preventative : 2/3 will have 50% reduction Many have significant side effects: Pizotifen – weight gain, drowsiness B- Blockers – tiredness Tricyclics – drowsiness Anticonvulsants – valproate, topiramate, gapapentin – significant s/e. Botulinum Toxin type A http://www.nice.org.uk/guidance/ta260 http://www.nice.org.uk/guidance/ta260 Candesartan : http://www.ncbi.nlm.nih.gov/pubmed/24335848 http://www.ncbi.nlm.nih.gov/pubmed/24335848

22. Medication Overuse Headache Headache present on at least 15 days per month Developed or markedly worsened during medication overuse Headache resolves or reverts to its previous pattern within two months on discontinuation Regular overuse for three months or more

23. Culprits Opiates, codeine +/- paracetamol 10 days+ per month Triptans or NSAIDs 15 days+ per month

24. Vicious Cycle Bad spell of headaches eg stress Take more painkillers Body gets used to medication Rebound/withdrawal if stop for>1d Think this is another usual headache Take more painkillers Problem worsens

25. Blood Pressure and Headache Very High BP can cause Headache Patients will Expect to have BP checked when presenting with Headache Children with Headache – check BP 3rd Trimester Pregnancy and Headache ?Pre-eclampsia

26. SINUSITIS HEADACHE Headache worse on lying down Nasal congestion Nasal discharge purulent +/- blood Cough, Fever, Malaise Tender at point of pain Can be unilateral Treatment: http://bjgp.org/content/63/616/611 http://bjgp.org/content/63/616/611

27. RAISED ICP New increasing headache Present on waking Increased by stooping or straining Changes in mental state Vomiting Papilloedema Causes: sinister and benign, acute and chronic

28. Idiopathic Intracranial Hypertension Link to Excellent summary: http://www.patient.co.uk/doctor/idiopathic- intracranial-hypertension-pro http://www.patient.co.uk/doctor/idiopathic- intracranial-hypertension-pro

29. SAH Risk factors similar to stroke eg. Smoking, hypertension Family History in 5-20% Incidence 6 cases per 100,000 patient yrs 50% fatality, 1/3 remain dependent Sudden explosive headache is the cardinal feature. If related to sexual intercourse ?SAH CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative

30. SAH A period of unresponsiveness of >1 h occurs in almost half of patients Focal signs develop at the same time as the headache or soon afterwards in one third of patients Classically, the headache from aneurysmal rupture develops in seconds, but can be minutes

31. SAH Vomiting occurs in 70% of patients Neck stiffness is a common sign in SAH of any cause, but takes hours to develop and therefore cannot be used to exclude the diagnosis if a patient is seen soon after the sudden-onset headache If thunderclap headache is the only symptom then 10% only will have SAH, but all need investigation

32. JULIE JONES, 45 TELEPHONE TRIAGE CONSULTATION (Dr A) Headache: started 3 days ago gradual onset worse last night Started to feel nauseous with it yesterday Analgesia does help Global but more at front left Slight dizziness with nausea no vomiting or visual disturbance of gross neurological symptoms Suggested comes in for examination but most likely tension type headache Fictional name and age for illustration

33. JULIE JONES, 45 FY2 CONSULTATION IN SURGERY (same day) 3/7 tension like headache, frontal. No photophobia Vomited 3x overnight Very stressed with work Had tension and migraines in the past Helped when lying down Not worse bending over No visual symptoms

34. JULIE JONES, 45 Unlikely to be pregnant - partner has had vasectomy. D/W Dr B Ibuprofen and paracetamol helped marginally o/e PEARL, no focal tenderness, appears anxious Discussed stress at work and sleep hygeine Advised to return if problem persists or deteriorates

35. JULIE JONES, 45 DISCHARGE LETTER Hosp to ITU (1 week later) Collapsed that evening and had seizure Intubated and ventilated Platelet count 6 Discussed with Haematology Diagnosis TTP To Have Plasma Exchange in Liverpool

36. JULIE JONES, 45 Edited Highlights: Had 3 cardiac arrests, Had plasma exchange Discharged after 3 weeks Medication started: Phenytoin, Prednisolone, Aspirin, Gliclazide Haematology follow up, Platelet count recovered Steroids reduced, gliclazide stopped Driving: notify DVLA. Cannot drive for 6 months

37. LEARNING POINTS?

38. UPCOMING SESSIONS 17th March – Women’s Health (Dr Helen Wall) 21st April – Genetics (Dr David Harniess)