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Diagnosis and management of primary headache

Learn the key elements of diagnosing and managing primary headaches, including migraine, tension-type headache, and cluster headache. Understand the importance of accurate history-taking, diagnostic criteria, and appropriate treatment approaches. This guide covers red flags, medication options, and lifestyle measures for chronic headache.

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Diagnosis and management of primary headache

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

  2. History taking in episodic headache • History taking in chronic headache • 3minute neurological examination • 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. 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”

  11. 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

  12. 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

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

  20. 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

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

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

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

  24. 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

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

  26. 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

  27. “ 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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