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Headache –why its not a pain in the neck

Headache –why its not a pain in the neck. Steve Elliot GPwSI Headache. Diagnosis of episodic headache Diagnosis of chronic headache Who to refer for scanning (Management of headache). “Listen to the patient. He is telling you the diagnosis” Sir William Osler (1849-1919).

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Headache –why its not a pain in the neck

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  1. Headache –why its not a pain in the neck Steve Elliot GPwSI Headache

  2. Diagnosis of episodic headache • Diagnosis of chronic headache • Who to refer for scanning • (Management of headache)

  3. “Listen to the patient. He is telling you the diagnosis” Sir William Osler (1849-1919)

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

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

  6. Guatama Buddha 563-483 BCHow to relieve suffering

  7. 8 questions - the way to end suffering in headache • Location? • Character? • Severity? • Aggravation by movement? • Nausea/vomiting? • Photophobia? • Phonophobia? • Duration?

  8. 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

  9. 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

  10. Cluster headache • Side locked unilateral • Peircing /drilling/grinding • Very severe • Not worse with movement • Possibly nausea/vomiting • Possibly unilateral photophobia • Possible phonophobia • 15-180 minutes duration • Autonomic symptoms • Restless

  11. 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

  12. Agree or disagree? “ ... She complains of frequent headaches and she has missed a lot of time off work. She is having to look after her demented mother and is under considerable stress. The headaches are throbbing and associated with nausea and occasional vomiting. She has been to A+E on two occasions. Neurological examination is normal. I feel she is suffering from chronic tension headache.”

  13. “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

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

  15. 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

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

  17. 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

  18. 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

  19. Neuroimaging guidelines- a brief summary

  20. What do we know? • Incidence of brain tumour in general population is 0.06-0.01% per year • 72% occur over age 50 • In primary care risk of brain tumour with headache presentation is 0.09% • If GP makes diagnosis of primary headache risk is 0.045% • If GP cannot make diagnosis then risk is 0.15% and 0.28% if >50

  21. What else do we know? • Risk of brain tumour >1% if Papilloedema New epileptic seizure Significant alteration consciousness, memory loss , co-ordination, confusion History of cancer elsewhere • Risk of lung cancer with haemoptysis 2.4% • Risk of colon cancer with positive FOB 7%

  22. 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”

  23. NICE, TWW and headache • Headaches in whom a brain tumour is suspected • Headache of recent onset accompanied by features suggestive of raised intracranial pressure eg Vomiting Drowsiness Posture related headache Pulse synchronous tinnitus Or by other focal or non-focal neurological symptoms eg blackout,change in memory or personality • New, qualitatively different,unexplained headache that becomes progressively severe

  24. Brain tumour headache • 55% new or changed headache • 5.1% “classic” raised ICP features • 55.1% not classifiable by IHS • 13.3% migraine • 23.5% episodic tension type headache • 40.8% occurred on 1-3 days per week • 60.2% “pressing/tightening” • 52% no trigger

  25. And... • 3-8% headache as only symptom • 74% brain tumours present within 3months • 90% within 6 months • Brain tumour headache may be similar to previous headache but more frequent/severe and associated with new symptoms

  26. Red flags-SIGN guidelines • New onset or change in patient over 50 • New onset headache with history of cancer • Abnormal neurological examination • Headache that changes with posture • Headache that wakes (most common migraine) • Headache precipitated by physical exertion/Valsalva • Non focal neurological symptoms eg cognitive disturbance) • Patients with risk factors for CVST • Jaw claudication or visual disturbance • Neck stiffness • Fever • Change in headache frequency,characteristics or associated symptoms • Thunderclap headache • Headache that changes with posture • New onset in patient with HIV • Focal symptoms <5min or >60 • Thunderclap heaadche

  27. Acute treatment migraine • Paracetamol • Aspirin or Ibuprofen • Anti-emetic Domperidone or Metoclopramide • Naproxen or Diclofenac • Triptan • Combination • AVOID OPIOIDS

  28. Which Triptan? • Almotriptan • Eletriptan • Frovatriptan • Naratriptan • Rizatriptan • Sumatriptan • Zolmitriptan

  29. Which Triptan? • 2 hour response • Chance of relapse • Adverse effects • Cost • Route of administration

  30. Prophylaxis of headache Tension type headache • Amitriptyline/Nortriptyline • (Mirtazapine) Migraine • Amitriptyline/Nortriptyline • Propranolol/Metoprolol • Topiramate • Sodium valproate or Gabapentin

  31. “ The very first step towards success in any occupation is to become interested in it” Sir William Osler (1849-1919) Canadian Physician

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