HEADACHE NATALIE HARTLEY ST2 AND ABIGAIL DOWNING ST1

‘A ubiquitous part of being human’ (Taylor et. al. BJGP 2014)

AIMS

To improve GPST knowledge regarding diagnosis and management of headaches, focussing on ‘Primary’ headaches; tension, cluster, migraine and also medication overuse headache (MOH).

OBJECTIVES

1. To appreciate the scale of the problem2. To be able to take a headache history3. To be alert to ‘red flags’4. To be able to do a 3 minute neuro

exam to exclude serious underlying pathology

5. To be aware of the key point in Ix/Mx of primary headache.

THE PROBLEM

Headache = sensation of pain felt within the skull.

Annual prevalence = 80% 4% of GP consultations and 33% of neurology

OP appointments. Primary headache costs the UK £5-7 billion a

year England has a ratio of 1 neurologist to 117,000

of the population. This is up to 10 x lower than elsewhere in Europe. (RCGP curriculum and APPGPHD, 2014)

HEADACHE HISTORY

16 RED FLAGS (NICE,2012)

Worsening headache +

fever

Sudden onset, max intensity in 5 mins – Worst

ever

New neurological

deficit

New cognitive dysfunction

Personality change

Impaired Consciousness

Recent head trauma (within 3

mo)

Triggered by cough, valsalva,

sneeze

Triggered by exercise

Orthostatic Headache

? GCA Visual Disturbance/Jaw claudication/ten

der scalp

? Acute closed angle glaucoma

– painful red eye, haloes, dilated pupil

Immunocompromised

Vomiting + no obvious cause

History of malignancy that metastases to brain or any if

<20

Substantial change in

pattern of normal headaches

ICHD-II CLASSIFICATION

Primary Headache

• 1. Tension• 2. Migraine• 3. Cluster + other trigeminal

autonomic cephalalgias• 4. Other - eg. hypnic headaches

Secondary Headache

•1. Post-traumatic – ICB, + also whiplash•2. Vascular – eg. Haemorrhagic stroke/ Temp arteritis •3. Non-vascular – eg. SOL, BIH•4. Infectious – eg. Meningitis, sinusitis•5. Disorders of Homeostasis – eg. phaeochromocytoma, PET, hypoglycaemic headache.•6. Headache attributable to disorder of neck, eyes, ears, teeth, sinuses eg. Acute glaucoma, TMJ, refractive error•7. Psychiatric – somatisation disorder, psychotic disorder•8. Attributable to a substance or its withdrawal – eg. MOH

EXAMINATION

‘Perform and understand the limitations of a screening neurological examination’ –RCGP curriculum

General appearance, temp. Blood pressure – patients will expect

this 3 minute neuro exam

CASE 1

Jane, 42, accountant.

CASE 1 DIAGNOSIS

Tension headache

‘Featureless’ Episodic <15/days mo. Chronic=.>15d Associated w/ stress

NICE, 2012:1. Give a positive diagnosis2. Do not offer neuro-imaging just for reassurance3. Do not offer codeine – offer aspirin/paracetamol/NSAIDS 4. Acupuncture may help (Cochrane, 2009)

5. Headache diary

HEADACHE DIARY

CASE 2

Felicity, 25, junior doctor.

CASE 2 DIAGNOSIS

Medication Overuse Headache

Headache occuring >15 days/month with associated use of: Simple analgesics, >15 days/month Ergot/codeine/triptans > 10 days/month Often secondary to TTH/Migraine

NICE, 2012/BASH, 2010:1. Explanation – paradoxical effect of analgesia 2. Abruptly stop all medication for at least 1 month – may need to plan

sick leave3. Close follow-up and r/v in 4-8 weeks. Address underlying disorder4. More common with ‘low acceptance of pain’ and ‘problem solving

mode’ – motivational interviewing may be necessary (Frich et al. 2014)

CASE 3

Scott, 35, teacher.

CASE 3 DIAGNOSIS

Cluster Headache

Possibly due to temp artery hypersensitivity to 5HT. ♂: ♀ 5:1 and smokers, 3rd/4th decade Headaches are stereotypical and occur in bouts of 6-12wks – once every year/

2 years

NICE, 2012:

1. Acutely – give 12l oxygen via NRB for 15 mins + nasal/subcut triptan eg. Zolmitriptan 5mg nasally (Simple analgesics won’t work)

2. DO discuss with Neurology. Some neurologists will want imaging w/ 1st attack3. Home oxygen - HOOF form4. Prophylactic Medicine – best evidence for verapamil. Needs an ECG

beforehand to check for AV block. Discuss with neuro if unfamiliar with this use. Specialist may also initiate lithium or methysergide.

CASE 4

Claire, 55, museum curator

CASE 4 DIAGNOSIS

Migraine

Moderate/Severe headaches, which impair routine activity, tend to be unilateral and throbbing, often associated with photo/phono-phobia, N&V.

Affects 10% population, twice as common in women 30% occur with aura (visual/somatosensory/speech/motor), the rest

without.

Cause: Neurovascular disorder. Hyperexcitable brain compared to non migraine sufferers and pain is referred inappropriately from the nociceptors in the meninges and intracerebral blood vessels. (BMJ learning, 2014)

Triggers (50%) (OHCM, 2014): C H O C O L A T E

MANAGEMENT OF MIGRAINE

NICE 2012:

Acutely: Offer an oral triptan + ibuprofen 600mg/paracetamol Consider antiemetic even if no nausea (eg. Domperidone 10mg /metaclopramide 10mg) Do not use opioids Do not refer for neuroimaging for reassurance DO refer if prolonged aura /motor symptoms or ? Stroke/TIA

Prophylaxis: Discuss trigger avoidance and preferences, but can try propranolol/ topiramate (note: teratogenic)

Second line, try acupuncture, gabapentin.  Riboflavin (400mg od ) may be effective – expensive.

Chronic Migraine >15 d/mo for 3 mo and not overusing medication: Botox may help

Menstrual Migraine: For predictable menstrual-related migraine consider treatment with triptain on the days migraine is

expected. NOTE: If female patient has migraine with aura avoid COCP – ischaemic stroke risk

5 T’S OF TRIPTANS

1. 5-HT1 agonist2. Treatment3. Timing4. Three5. Take 2nd dose6. Trouble

AM I MISSING A BRAIN TUMOUR?

Rare - disproportionately affect younger pts Kernick et al., 2008: 0.045% risk at 1 year risk of

malignant brain tumour in those diagnosed with primary headache in GP.

Tumours rarely cause headache until quite large (except for pituitary tumours) at which point likely to be other signs/sympts of raised ICP (seizures/papilloedema)

NICE is clear that neuroimaging should not be offered for reassurance if clear Hx migraine/tension headaches

5% MRI heads bring up incidental findings, anxiety and F/U needed. Insurance implications.

SUMMARY

Headache is common History and Examination is crucial to

exclude potentially serious causes Much of the burden of primary

headache management is achievable in GP, with appropriate access to secondary care as necessary

THANK YOU FOR LISTENING

Any questions/cases?

REFERENCES + RESOURCES APPGPHD (All Party Parliamentary Group on Primary Headache Disorders), 2014. Headache Service in England. A

report of the All Party Parliamentary Group on Primary Headache Disorders 2014. Published by the House of Commons. Available from: http://headacheuk.org/May%2014-%20Full%20Report.pdf

BASH, 2010. Guidelines for all Healthcare Professionals in the Diagnosis and ManAgement of Migraine, Tension Type Headache, Cluster Headache and Medication Overuse Headache. 3rd edition (1st revision 2010). Available from: http://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf

BMJ Learning, 2014. Migraine: patient experience, understanding of pathology, therapies. Video module available from: http://learning.bmj.com/learning/module-intro/migraine-patient-experience-pathology-therapies.html?moduleId=10021852&searchTerm=%E2%80%9Cmigraine%E2%80%9D&page=1&locale=en_GB

Cochrane Pain, Palliative and Supportive Care Group, 2009. Acupuncture for tension-type headache. Published Online: January 2009 Assessed as up-to-date: 14 APR 2008 Available from: http://www.thecochranelibrary.com/details/browseReviews/579023/Headache--migraine.html

Frich, J et al. 2014. e GP’s experiences with brief intervention for medication-overuse headache: a qualitative study in general practice British Journal of General Practice 64(626) e525-e531; Available from: http://intl.bjgp.org/content/64/626/e525

GP notebook, 2014. Available from; http://www.gpnotebook.co.uk/homepage.cfm Headache Classification Subcommittee of the International Headache Society, 2004. The International Classification of

Headache Disorders 2nd Edition. Cephalalgia 24:1 Available from: http://www.tna.org.uk/data/files/Professional_Subjects/Intl.%20Classn.%20of%20Headaches.pdf

Kernick, D. et al. 2008. What happens to new onset headache presented to Primary Care? A case cohort study using electronic primary care records. Cephalalgia. 28:118-1195

NICE, 2013. NICE Quality Standards[QS42]: Headaches in Adults and Young People. Published online August 2013. Available from: http://www.nice.org.uk/guidance/QS42

Longmore, Murray. et al. Oxford Handbook of Clinical Medicine 9th edn. (p460-463). Oxford University Press 2014 Taylor, T. Et al. 2014. Headache: Two view on the right approach in General Practice. British Journal of General

Practice 64 (626) 475-476 Available from: http://bjgp.org/content/64/626/475