1. Dr David PB Watson GPwSI Hamilton Medical Group Aberdeen
OH and Headache
Dr David PB Watson
GPwSI
Hamilton Medical Group
Aberdeen

2. Objectives Headache impact and epidemiology Headache diagnosis
Headache management
audit and useful information
case study

3. Headache Impact and Epidemiology
Objective 1
Headache Impact and Epidemiology

4. Headache types Primary headache Secondary headache
Episodic primary headaches
Chronic primary headaches
Primary headache
No underlying medical cause:
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
Secondary headache
Underlying medical cause:
Headache can be a primary disorder or a secondary symptom of another disease. Primary headache may also be secondary to another disorder, for example, the relationship between cervical spine disorders and migraine headaches.
The headache classification system of the International Headache Society (IHS), first published in 1988 but recently revised (2004), lists >100 types of headache, many of which are attributable to pathological conditions (IHS 1988, 2004).
Secondary headaches are common in patients with an intracranial process, including tumour, haemorrhage, infection or vascular disorders. They may also be associated with systemic infections, the use/overuse of various drugs and head injury.
Primary headaches (eg episodic primary headache, chronic primary headache, migraine, tension-type headache [TTH] and cluster headache) have no obvious underlying cause.
Accurate diagnosis of headache type is critical to the therapeutic recommendation. Secondary headache to an underlying disorder must be excluded, followed by a correct primary headache diagnosis and treatment plan.

5. Episodic primary headaches
Migraine +/- aura
Tension-type headache (TTH)
Cluster
Probable migraine
There are four types of episodic primary headaches (IHS 2004):
Cluster: episodic cluster headaches occur in periods lasting from 7 days to 1 year and are separated by pain-free periods lasting 1 month. Pain is severe and unilateral. Attacks are associated with 1 of the following signs: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and eyelid oedema.
Tension-type: episodes of headache lasting days to months. The pain is typically bilateral, pressing or tightening in quality, of mild-moderate intensity and does not worsen with physical activity. There is no nausea, but photophobia may be present.
Migraine ± aura: patients have periods of severe impairment followed by return to a normal neurological baseline. Headache pain is often unilateral, of moderate intensity and pulsating quality. The headache is worsened by physical activity and is frequently associated with nausea, photophobia and phonophobia.
Probable migraine: previously categorised as ‘migrainous headache’. This diagnosis is given if the headache is missing 1 features of migraine ± aura.

6. Chronic primary headaches / chronic daily headaches
Chronic cluster
Chronic migraine +/- medication overuse
Chronic tension
Chronic daily headache (CDH)
Hemicrania continua
New daily persistent
There are five forms of chronic primary headaches (also known as chronic daily headaches [CDH]) (IHS 2004):
Chronic migraine: diagnostic criteria for migraine without aura and occurs on 15 days/month for >3 months in a row. May be associated with medication overuse.
Chronic tension: diagnostic criteria for tension headache and occurs on 15 days/month for >3 months in a row. May be associated with medication overuse.
Chronic cluster: diagnostic criteria for cluster headache, but with attacks for 1 year without remission or with remission periods of <1 month.
New daily persistent headache: starts acutely and continues as constant unremitting pain, lasting >4 hours/day and occurring 15 days/month for 1 month.
Hemicrania continua: persistent unilateral, stabbing, continuous pain specifically located in the trigeminal nerve. Accompanied by 1 of conjunctival injection ± lacrimation, nasal congestion ± rhinorrhoea, ptosis ± miosis.

7. Lifetime prevalence of primary headache
Episodic migraine
Episodic TTH
Chronic daily - all types
16%
78% 4%
This slide presents findings from the first prevalence study of headache that used operational diagnostic criteria of the IHS to classify headache disorders.
975 eligible adults aged years who lived in Copenhagen, Denmark, were invited to participate in the study (76%) of the invitees agreed to participate.
Participants were examined by a neurologist using a structured interview questionnaire and clinical examination.
The overall lifetime prevalence of episodic migraine was 16% (119/740).
The overall lifetime prevalence of episodic TTH was 78% (578/740). This is a higher prevalence rate than that reported by previous studies and may be a reflection of the more accurate diagnostic criteria used in this study.
The findings of the study highlight that headache disorders are prevalent in the general population and are a major health issue.
(n=740)
Rasmussen et al 1991

8. Impact Episodic TTH –low (common) Episodic Migraine – high (1 in 10)
Chronic Daily Headache - high ( 1 in 25)
Cluster – very high (1-2 in 1000)

9. Migraine Impact Meets WHO definition of disability Epidemiology
6 million people in UK
Women 3x men
most sufferers aged 20 to 50

10. Personal Impact 187000 migraine attacks experienced every day
3/4 report disability at least sometimes
1/3 feel migraine controls their lives
47% of migraineurs experience depression compared 17% on non migraineurs

11. Impact of Migraine UK migraine survey 1999 showed that
30% were unable to look after their family
63% were either totally or significantly prevented from going to work
39% had suffered an attack whilst driving

12. Economics of Migraine
50% of migraine sufferers miss up to 26 days work a year
18 million working days a year lost
lost productivity valued at almost £2 billion a year
sufferers function at 50% efficiency with migraine symptoms for up to 1 week

13. Migraine sufferers (%)
Indirect cost of migraine For most sufferers, migraine results in lost productivity rather than days lost from work
Work loss (%) 20 40 80
100 60
The most severely affected sufferers (40% of the sample) accounted for all days lost from work
Almost all sufferers reported reduced productivity equivalent to lost work days
The impact of migraine on work performance was evaluated over a 3-month period in a sample of 122 migraine sufferers who were in regular, paid employment (von Korff et al 1998).
In this survey, reduced work performance was measured in terms of work days lost (WDL) or loss of work day equivalents (LWDE; defined as partial work days lost + work productivity lost from reduced effectiveness while at work).
Although most migraine sufferers did not report any WDL caused by migraine, the large majority claimed migraine caused 1 LWDE.
The figure presents cumulative percentages of total disability, estimated by ranking the migraine sufferers from the highest to the lowest in terms of WDL and LWDE. These data show that all the WDL and 75% of the LWDE reported in the survey were specifically associated with 40% of the migraine sufferers sampled. This localisation of reduced workplace performance to this specific group of migraine sufferers suggests that out of the whole sample, these 40% may have been the most severely affected.
These data confirm that migraine attacks may reduce workplace performance and suggest their impact on this may be related to migraine severity. 10 20 30 40 50 60 70 80 90
100
Migraine sufferers (%)
Adapted from von Korff et al 1998

14. Objective 2 Headache Diagnosis
This slide kit is for educational purposes only

15. “Red flags” Single cohort (Level 3) or expert opinion (Level 4)
new onset headache in patients who are aged over
abrupt onset (thunderclap) 28-30, 32, 33
focal symptoms including atypical aura greater than one hour 28, 32, 34, 35
abnormal neurological examination 28, 29, 35, 36
altered mental status 28, 30, 34
altered characteristics or associated features of headache 28, 31
headache that changes with posture 37
headache worse in the morning and during physical activity, and the valsalva manoeuvre 28, 38
patients with risk factors for thrombosis 34, 39, 40
new onset headache in a patient with a history of HIV infection 41
jaw claudication 16
neck stiffness 30
fever 42
new onset headache in a patient with a history of cancer 9

16. Abbreviated diagnostic checklist based on IHS 2004 criteria
Migraine
Probable migraine
Tension-type
Essential (3)
Essential (2)
Essential (1)
Recurrent
No organic disease
Duration 4-72 h
Unilateral
Pulsating
Moderate / severe
Aggravated by movement
Nausea / vomiting
Photo / phonophobia
Recurrent
No organic disease
Duration 4-72 h
Moderate / severe
+ one other
Recurrent
No organic disease
Duration 0.5 h-7 days
Generalised
Pressure / tightness
Slight / moderate
Photo / phonophobia
Although migraine, migrainous headache and tension-type headache are all primary episodic headaches, each has characteristic differentiating features. The IHS has used these features to develop diagnostic criteria for each of these headache types (IHS 2004).
This slide presents an example of how an abbreviated diagnostic checklist for headaches can be derived from the clinical criteria provided within the International Classification of Headache Disorders (IHS 2004). The checklist was developed by Dr Robert Smith in order to facilitate use of the IHS criteria in the primary care setting (unpublished).
Essential (3) = all items essential for diagnosis; Essential (2) = two items from list essential for diagnosis; Essential (1) = one item from list essential for diagnosis
IHS 2004

17. What features make migraine more likely?
episodic severe headache that causes disability11, 23, 24
nausea16, 23
sensitivity to light during migraine headache16, 23
sensitivity to light between migraine attacks 25
aura16, 18
sensitivity to noise16
exacerbation by physical activity16
positive family history of migraine16
The features which give the greatest sensitivity and specificity are disability, nausea and sensitivity to light23
ID Migraine validation study (Level 3)

18. Other primary headache
Trigeminal autonomic cephalalgias (TACs)
Cluster headache
Paroxysmal Hemicrania
SUNCT
Hemicrania continua
New daily persistent headache

19. What features make TACs more likely?
The following features differentiate trigeminal autonomic cephalalgias from migraine: 16, 26 (Level 4)
Onset: rapid in TAC, gradual in migraine
Duration: TACs < 3 hours, migraine hours
Frequency: multiple attacks may occur daily in TACs
Restlessness during an attack: 100% in cluster headache, 50% in paroxysmal hemicrania
Prominent ipsilateral autonomic features in TACs
Features which differentiate trigeminal autonomic cephalalgias from each other and from trigeminal neuralgia are listed in Annex 2

20. Diagnosis Summary Key question is impact
Default diagnosis for intermittent headache is migraine(Landmark study 90%)
Migraine v Cluster imagine typical patient
Chronic headache consider medication overuse

21. Objective 3
Headache Management

22. Non-pharmacological therapies
Behavioural treatments include:
stress management / relaxation training
regular diet and sleep
trigger identification and avoidance
avoidance of excessive over-the-counter medications
Physical treatments include:
natural remedies / complementary medicines
acupuncture
transcutaneous electrical nerve stimulation
occlusal adjustment
cervical manipulation
Migraine may be treated pharmacologically or non-pharmacologically.
Non-pharmacological methods are generally used to prevent migraine episodes rather than alleviate symptoms once an attack has started. However, the US Headache Consortium Headache Guidelines suggest they may be considered for patients who
prefer non-pharmacological interventions
have low tolerability for specific pharmacological treatments
have medical contraindications for specific pharmacological treatments
have insufficient or no response to pharmacological treatment
are pregnant, planning to become pregnant or nursing
have a history of long-term, frequent or excessive use of medications that aggravate headache problems or lead to decreased responsiveness to other pharmacotherapies
have significant stress or deficient stress-coping skills.
The slide presents several non-pharmacological treatment options that are widely used in clinical practice.
Adapted from US Headache Consortium Headache Guidelines

23. Acute pharmacological therapies
Drug class
Analgesics
5-HT1B/1D agonists
(Triptans)
antiemetics
Drug name
Aspirin 900 mg, ibuprofen 400mg
Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan ,zolmitriptan
Domperidone, prochloroperazine
Avoid opioids
Until the introduction of the 5-HT1B/1D agonists (ie triptans) in the early 1990s, acute treatment options were limited to simple analgesics, NSAIDs or ergotamine derivatives.
Mild migraine attacks are typically treated with analgesics and anti-inflammatory drugs, specifically aspirin, paracetamol (acetaminophen), ibuprofen, and naproxen. Moderate migraine attacks are treated with triptans. Triptans are often used to treat severe migraine.
Patients should be cautioned that regular use of symptomatic treatments, such as analgesics, can result in medication-induced rebound headache and, eventually, chronic daily headache. Effective treatment, individualised to the patient’s headache type and severity, should minimise the risk of escalating drug use, which may lead to rebound headaches.

24. Management Summary
Provide acute medication to all migraine patients and recommend it is taken early
Provide rescue medication
Tailor treatment to the individual
Prophylactic Rx if high impact
Lifestyle management important

25. Audit Useful Information
Objective 4
Audit
Useful Information

26. Ideas for Audit Number of Migraineurs
Assess migraine impact and lost time
Migraine awareness campaign
Medication Overuse awareness
Reassess impact and lost time

27. Migraine Resources
British Association for the Study of Headache
Migraine Action Association

28. Objective 5
Case Study

29. Migraine and Sickness absence
Triggers
Long hours
Stress
Sleep disturbance
Missing meals
Travel/jet lag
Office lighting
Hormones
Disabling headache and ? DDA
Reasonable adjustments eg dark room, lie down, flexi time,
No medication 100% effective, acute treatment side effects

30. Case Study
ITU nurse aged 28 with chronic migraine and medication overuse headache
Issues include
Shift work affecting sleep, diet, exercise
Work pressures, short staffed, studying for exam, often lack of senior staff, management attitude to sick leave, lack of understanding/empathy from colleagues

31. Any Questions?