1. Patient presenting with headache Migraine/CDH low High Q1. Headache impact ATTH Q2. No. of headache days per month > 15 < 15 Chronic headache Q3. Analgesic days/week <2 >2 Not analgesic dependent Analgesic dependent Migraine Q4. Reversible sensory symptoms With aura Without aura Yes No Consider sinister headache Consider short-lasting headaches Headache Pathways David Kernick St Thomas Health Centre Exeter

2. To a man with a hammer Everything is a nail

3. All headache is migraine

4. Classifying headache

5. IHS Headache classification Primary Secondary nMigraine nTension type nCluster nTraumatic nVascular nNon-vascular nSubstance induced nInfection nMetabolic nFacial structures

6. What do people think when they present with headache? nI need glasses (<1% headache due to undiagnosed refractive errors) nIts my blood pressure nI have a tumour

7. What do GPs think patients have? Kernick 2009

8. What do patients have when they present to GP with headache? n80% migraine n15% Tension type headache n5% secondary headache

9. Is it a tumour?

10. Probability of significant pathology >1%. Need urgent investigation Red Flags

11. Headache presentations where probability is likely to be 0.1% and 1%. Need careful monitoring Orange Flags

12. Probability of underlying pathology is <0.1% but above background. Needs appropriate management and follow up there are no green flags Yellow Flags

13. Headache and tumour nHeadache prevalence with tumour 70%+ nHeadache at presentation 50% nHeadache alone at presentation 10% (Iverson 1987)

14. Population 100,000 adults each year: n220,000 population headaches n4000 GP headaches n1 tumour will present as isolated headache

15. Risk of brain tumour and headache presenting to primary care (Kernick 2008) Headache overall – 0.09% Non headache - 0.02% Risk % Undifferentiated headache Primary headache All ages0.15%0.045%

16. Risk of brain tumour and headache presenting to primary care (Kernick 2008) Risk % Undifferentiated headache Overall0.15% Under 500.08% Over 500.28%

17. Scan when advantages over weigh disadvantages The advantages: n Better management - improved quantity and quality of life if positive nAllay anxiety - reassurance if negative

18. The disadvantages nResource implications nExposure radiation with CAT scan nExposes incidental abnormalities Population 0.6- 6% average 2.7% ( Morris 2009) GP requests 10% (Thomas 2010)

19. Luftwaffe pilots (n-2370) Weber 2006 n93% normal (25% variations of norm) n6.7% abnormalities n56 cysts; 13 vascular abnormalities;4 adenomas; 4 tumours

20. In reality the inputs are complex nLimited poor quality evidence base nExpert opinion nMedico-legal case law nPatient-doctor characteristics and approach to uncertainty nOrganisational factors

21. Do something now nMeningitis nThunderclap headache nTemporal arteritis nCarbon monoxide nMalignant hypertension

24. Do something soon nHeadache with abnormal neurological examination nHeadache with recent history of fits nHeadache with orgasm (first presentation – now) nHistory of cancer elsewhere or or HIV nExercise induced headache (not pre orgasmic) nPrecipitated by Valsalva manoeuvre, cough

26. Keep close eye and think carefully nHeadache with significant change in pattern n Awakes from sleep nNew headache over 50 years nNew Cluster headache nWorse on standing nIf a primary headache diagnosis has not emerged in an isolated headache after 6-8 weeks

27. Diagnose a primary headache nExclude medication overuse headache nDiagnose migraine, Tension type or Cluster

28. Medication overuse headache Headache intensity Migraine attacks Frequent ‘daily’ headaches Withdrawal of all analgesia Return of episodic headache Increased frequency of headache, associated with increased frequency of analgesia use. Daily headache with spikes of more severe pain

29. Simple Diagnostic aid nMigraine – have to lie down nTension headache – can keep going nCluster Headache – have to bang head

31. Formal Migraine n4-72 hours nTwo of : unilateral, pulsating, moderate or severe pain, aggregation by physical activity. nAt least one of: nausea/vomiting, photophobia, phonophobia.

32. Other diagnostic pointers for migraine nI feel nauseated nI don’t like light or sound nMovement makes things worse

35. Activation anywhere in the system can lead to output in any other part of the system and vici versa

36. Formal Tension Type n30 minutes – 7 days. n2 of : bilateral, non-pulsating, mild/moderate, not aggravated by activity. nNo nausea, vomiting, photophobia, phonophobia.

37. Thalamus + Mid Brain structures Medication overuse headache Tension type headache AURA CERVICAL NUCLEI MIGRAINE CENTRE Hypothalamus CLUSTER Headache model

38. Migraine treatment Acute n Paracetamol/Asp/Domperidone nRectal NSAI/Domperidone nTriptan

39. The Triptans nTablets, melts, nasal spray, injection. nSide effects nFailure response is not a class effect nTreat onset of pain nOver 65 years?

41. Migraine prevention nBeta blocker nAmitriptyline nTopiramate

42. GPwSI? nNot secondary headache exception medication overuse headache nUnsure of diagnosis if red flag excluded nPrimary headache difficult to treat n? New cluster

43. Five key questions nHow many types of headache do you get? nIs there a family history of troublesome headache? nWhat pain killers are you taking? nWhat is the impact of your headache? nWhat do you think is causing it?

44. Two key examinations nBlood pressure nFundoscopy

45. One key delaying tactic nGo away and keep a diary nMake a double appointment next time