Headache Service in CumbriaDr. Jitka Vanderpol MD FRCPCumbria Consultant Neurologist

• 47% of adults aged 18–65 years have had a headache in the last year

• 12-15 % of the UK population suffer from migraine• Migraine is among the 20 most disabling lifetime

conditions • 25 million working or school days are lost every year

due to migraine• It costs the UK economy over £3 billion per year in lost

working hours and doctor’s visits

Introduction

Objectives

• Give an overview of the current headache service in Cumbria

• Recognise primary & secondary headache syndrome

• Investigate and manage accordingly

• Refer where appropriate to ED or specialist

Headache Service in Cumbria

20-25% of all referrals to Neurology

Headache Service in Cumbria

• Led by a Consultant Neurologist with special interest in Headache

The Service Provides:• Assessment • Diagnosis• Advice about management• Investigations, brain imaging where appropriate• Treatment requiring interventions (GON block, Botox)• Opportunity to be enrolled to the Research trials

Whom to refer to specialist? & whom to ED??

•Majority of sudden onset headache patients require admission for cerebral imaging and possibly a lumbar puncture.

Red Flags

• Sudden onset of very severe, the worse ever headache

• Age of onset > 50 years (Giant cell arteritis)

• Increased frequency or severity

• Previous head trauma, especially with loss of consciousness

• Underlying medical conditions (HIV, cancer)

Red Flags

• Meningism - Raised Temperature - Vomiting

• Focal neurology (speech, power, balance)

• Associated: fever, rash, confusion, stiff neck, seizures• Headache that changes with posture • Headache on awakening • Precipitated by physical exertion or Valsalva

manoeuvre (e.g. coughing, laughing, straining) • Jaw claudication or visual disturbance

Case Study 1

• 42 year old woman became aware of a mild global headache while warming up for her aerobic class. Several minutes later (before the class started), she had sudden exacerbation of her headache, followed by vomiting and photophobia.

……..she was seen by GP

Case Study 1

• She was seen by her GP, who diagnosed migraine and gave her intramuscular Morphine and Prochlorperazine.

• She spent the next four days in bed with her worst ever headache (she had a previous history of migraine without aura, but this was much worse).

• On day 6 she was seen by a different GP who recognised the significance of her symptoms and referred her urgently to ED.

????

Case Study 1

• On examination she looked mildly unwell and distressed, but had no signs.

• CT brain scan reported initially as normal

• LP 4000 red cells in three successive bottles, but no visible xanthochromia.

• A diagnosis of late presenting SAH was made, the aneurysm was confirmed on angiography, and this was successfully coiled. Discharged with no neurological deficit.

Non-contrast CT brain day 6 of subarachnoid haemorrhage

• In retrospect, a neuroradiologist identified a probable anterior communicating artery aneurysm and blood in the interhemispheric fissure

Case Study 2 - John

Discussion

Cluster Headache

Cluster headache is trigeminal autonomic cephalgia

• Severe unilateral usually sharp short lasting pain• Trigeminal distribution • Associated with trigeminal autonomic features • - tearing from eye• - drooping eye lid• - redness of face• - blocked nostril• Typically restlessness during the attack.

Investigation & management

Migraine

•Episodic•Unilateral •Throbbing •Associated with nausea or vomiting •Aura (15–33% of patients) •Exacerbation by physical activity•Light sensitivity•Often positive family history of migraine•Normal neurology assessment•No red f lags

Medication Overuse Headache

• Headache (headache ≥15 days / month for >3 months).

• Patients using any acute or symptomatic headache treatment are at risk of medication overuse headache.

• Patients with migraine, frequent headache and those using opioid-containing medications or overusing triptans are at most risk.

Key Recommendations

• Patients who present with a pattern of recurrent episodes of severe disabling headache associated with nausea and sensitivity to light, and who have a normal neurological examination, should be considered to have migraine.

• Patients with a first presentation of thunderclap headache should be referred immediately to hospital ED for same day assessment.

• Patients who present with headache and red flag features should be investigated further.

Key Recommendations - Investigations

• Neuroimaging is not indicated in patients with a clear history of migraine, without red flag features for potential secondary headache, and a normal neurological examination.

• In patients with thunderclap headache, unenhanced CT of the brain should be performed as soon as possible and preferably within 12 hours of onset.

• Patients with thunderclap headache and a normal CT should have a lumbar puncture.

Resources

• BASH guidelines• NICE 150• SIGN 107 Diagnosis and management of headache in adultsFurther info: http://guidance.nice.org.uk/CG150http://www.bash.org.uk/http://www.migrainetrust.org/health-professionals/guidelineshttp://www.sign.ac.uk/pdf/sign107.pdf