1. Diagnosis and management of primary headache
Steve Elliot
GPwSI Headache

4. History taking in episodic headache
History taking in chronic headache
3minute neurological examination
Who to refer for scanning
(Management of headache)

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

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

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

9. Guatama Buddha 563-483 BC How to relieve suffering

10. 8 questions - the way to end suffering in headache
Location?
Character?
Severity?
Aggravation by movement?
Nausea/vomiting?
Photophobia?
Phonophobia?
Duration?

11. 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

12. 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

13. 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”

14. 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

15. 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

17. “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

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

19. 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

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

21. 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

22. 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

23. Don’t forget BP Palpate temporal arteries >50 ESR/CRP >50
DOCUMENT WHAT YOU DO

24. Acute medication in migraine
Paracetamol
Aspirin 900mg
Naproxen 500mg
Domperidone if nausea
Consider suppositories
Almotriptan 12.5mg
Other triptan if Almotriptan ineffective
Zolmitriptan nasal spray
Sumatriptan injection

25. Prophylaxis Propranolol 80-240mg Amitriptyline 10-100mg
Pizotifen if young
Topiramate or Epilim
Take 6-8 weeks to kick in
See regularly

26. Don'ts in migraine treatment
Over the counter
Opioids
Caffeine
Migraleave
Analgesia more than 2-3 days per week

27. Sir William Osler again
“One of the first duties of the physicians to educate the masses not to take medicines”

28. Medication overuse headache
Headache >15 day per month
Intake of following for 3months
Simple analgesia >15 days per month
Or Opioids/triptans/combination analgesia >10 days
per month
Headache resolves or returns to previous pattern within 2months of discontinuation of analgesia

29. What do you do when you get a headache?
Stay still =Migraine
Pace up and down = Cluster
Take tablet = Medication overuse

30. Management of chronic headache
Exclude red flags
Establish phenotype
Lifestyle measures
Avoid caffeine
Stop analgesia
(Occasional Naproxen)
Start prophylaxis according to phenotype
Regular follow up

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