gp headache slides sept 2016
TRANSCRIPT
Contents
• GP liaison role• Headaches
o Migraineo Tensiono Medication Overuse Headacheo Clustero Trigeminal Neuralgia
GP liaison• Education
o Feb + May 2016• Communication/referrals
o A+Go Routine clinicso Rapid access clinics
• Pathwayso Headache o Bells Palsyo Tremor/PD (next)
[email protected]@nhs.net
Headache• Common• 4.4% consults in 10 care• 30% neuro OPD• Primary v Secondary• Sinister headache in 0.1% 10 care
• Est migraine £2 billion/yr to UK• 100,000 people off work/school due to
migraine each day
NICE 2012
• Important to make a +ve diagnosis
History• Age• Character/distribution/triggers• Pattern of headache over time• Previous headache• Associated features• What do they do if bad?• Any neuro symptoms?• Medication – inc OTC• FH
Examination (2-3 mins)
• Fundi• Fields and eye mvmts• Pyramidal Drift?• BP• Quick limb inc reflexes• Neck mvmts?
• If over 50 think about temporal art palpation
Warning FeaturesThunderclapAtypical auraNew onset if > 50yrsProgressive, severeCognitive/personalityFeverSymptoms raised ICP
Drowsy, postural, vomitingHx cancer/HIVProgressive neuro deficitPapilloedema
Case 138 yr old womanHeadaches 4 yearsOcc, then increasing freq3-4 days per week severe, daily acheCan wake with h/acheWorse if bends overSome nauseaNo visual symptomsTaking paracet and ibuprofen most daysCodeine when severeNil on exam
• Any photophobia? mild• What does she do when severe? Lies
down• How long do severe episodes last? Few
hours• Any stresses? no• Hormones? no• FH? Mother migraine• How often codeine? 3-4 days per week
• Diagnosis – migraine +/- MOH• No tests needed except BP
More History:
NICE 2012
• Do not scan primary headaches for reassurance
Migraine• Life time prev 10% men 22% women
• Characteristicallyo Unilat (40% bilat)o Throbbingo Build up over mins/hrso Moderate – disablingo Worse with activityo Nausea*/vomito Photo*/phonophobia * = most sens/specific
Auras• 15-30% migraines• Usually “positive”
• Visual• Tingling
• Occ negative • Numbness• Dysphasia
• 5 – 60 mins• Can get without headache• DD TIA – short, sudden,
negative
Migraine - misdiagnoses
50% misdiagnosed
4-72 hrs – can be longer 75% neck pain <33% vomiting Often coexist Chronic - 15 days/month over 3/12 – features
of tension/MOH
Management• Identify triggers
o Stress/sleep dep/diet• Massage/acupuncture etc• Withdraw any overused
meds• Headache Diary
Management
Acute:ASA 900mg NSAIDs – ibuprofen (dicofenac pr)+/-Antiemetics
Domperidone/metoclop bestOcc codeine? *cautionCombination asa + caffeine + para
TriptansFor use at onset headacheEffective in 50%Delivery methods
Oral – all – sumatriptan cheapestS/L – riza + zolmitriptanS/C or nasal - sumatriptan
If no response try alternativeCombination with ASA/NSAIDC/I IHD or severe hypertensionCaution with hemiplegic migraine?
Prophylaxis – general principles
• Given if affecting QOL• Titrated slowly• Trial 6-8 weeks• If effective consider withdrawal
after 6-12/12
Prophylaxis• Propranolol LA 80mg - 240mg
o Caution asthma, bradycardia, PVD
• Topiramate 25mg – 50mg bdo Caution kidney stones/depression/teratogenicity?
• Amitriptyline 10mg – 75mgo Good if chronic/mixed
• Valproate 800-1200mg/dayo Caution young women
• Gabapentin up to 2400mg/day• Pizotifen minimal benefit
Alternatives:• Atenolol/metoprolol• Nortripyline• Venlafaxine 75-150mg • Candesartan 8-32mg• Methysergide – close supervision
• PFO – no benefit • Bo tox • recent license chronic
migraine• >3 prior Tx• No MOH
Women + migrainePregnancy
Paracetamol ASA 300mg/ibu 400mg in 1st/2nd trimester (NICE)
COC Migraine + aura + COCP RR 9 stroke >35yrs no aura also increased risk
Menstrual migraine 2/7 prior: Mefanamic acid/asa/parac/caffeine/triptan (fovatriptan od, naratriptan
bd)
Who to refer?• Unsure of diagnosis• Atypical migraine
o Motor weaknesso Diplopiao Poor balance
• If adequate trial propranolol/amitrip/topiramate ineffective
• Patient reassurance
Case 2• 25yr old man• 6 month headache• Generalised, tight• Most days• Neuro examination normal
• What further history?
History• Does he wake up with it? no• Daily variation? comes on through day• How severe? Can carry on activities• Associated n, v, photo/phono? no• Analgesia? Occ parac• Relieving/agg factors? No
• Diagnosis – Tension type headache
Tension Headache• 50% population• Episodic/chronic (>15 days/month)• Mild/mod• Featureless• No nausea• Occ scalp tender/photo/phono• Often overlap/misdiagnosis with migraine
Management• Massage/acupuncture/lifestyle• Acute
o ASA or paracetamolo NSAIDs
• Prophylaxiso Amitrip/nortrip up to 75mgo ?underlying depressiono Venlafaxine/mirtazepine
Medication overuse Headache
• Usually in migraineurs/10 headache
• If h/ache >15 days/month began/worsened whilst taking analgesia
• At risk if:• Triptans/opiods >10 days/month• ASA/para/NSAIDs >15 days /month• For >3/12
Management MOH• Abrupt withdrawal >1/12• Opioids – gradual• Treat any dependence• Consider prophylaxis if fails
o Topiramate of propranolol
• Warn H/ache will worsen initially• Review at 4-8/52
Case 3• 50 yr old man• 3/52 headache• R sided severe for 30 mins • Background ache• No visual symptoms• Notices droopy R eyelid when severe
• What other questions?
History case 3• Always right side• Tearing – yes• Excruciating• Doesn’t know what to do – wants to bang
head off wall• 5 per day – mostly through night• No prev headache• No medication helps• Examination normal
Diagnosis?
Cluster Headache
Trigeminal autonomic cephalgiaPrev 1/1000Male middle age Strictly unilatOften nightAggitated TearingHorner’s<8/day
Cluster headache management
oMRI
o Treatment:• Acute – triptan (s/l, s/c), O2, steroids • Prophylaxis – verapamil
oRefer all
Adult with Headache
Emergency symptoms?1 Refer to appropriate on-call hospital team
Red flags?3
Use Advice & Guidance Service or refer general neurology
Can you make a diagnosis of
primary headache disorder?
Prescribe acute treatment (< 10 days/month)4
Refer to headache clinic
Inadequate response to migraine preventatives. Is it
chronic daily headache (>15/7 per month)?Use headache diary
Migraine or tension headache4 ?
Giant cell arteritis?2
• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura• Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect from
caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger
avoidance, stress management techniques, normalise BMI, daily aerobic exercise)Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:
teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.
c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture
Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse.
Cluster headache?5
Try acute treatments5
Check ESR and CRPPrednisolone 60mg o.d. immediately
Consider urgent referral to rheumatology as appropriate2 (Need temporal artery biopsy
within 2 weeks of starting prednisolone)
Yes
Yes
No
No
No
No
Yes
Northern East Headache Management GuidelineNovember 2015
Refer Neurology emergency clinic
(fax 0191 2824370)
Yes
Yes
No
1)
3)
Migraine (don’t need a full house!)• Throbbing pain lasting hours - 3 days• Sensitivity to stimuli: light and sound, sometimes smells• Nausea• Aggravated by physical activity (prefers to lie/sit still)Aura (if present):-
• evolves slowly (in contrast to TIA/stroke)• lasts minutes - 60min
‘Chronic Migraine’≥15 headache days/month of which ≥8 are migraineAcute treatments:Aspirin disp. 900mg or NSAID, taken with prochlorperazine A triptan, but no more than 9 days per month (best <6/month)Don’t use opiates as they tend to lead to increase nausea and lead to an overuse headachePoor absorption common in a headache attack – therefore better efficacy with anti-emetic, or non-oral (e.g. diclofenac supp, s/c or nasal triptan)
Tension Type HeadacheBand-like acheMostly featurelessCan have mild photo OR phonophobia but NO nauseaMany believe this is simply a milder form of migraine (i.e. same biology and thus similar treatments can be effective)
Cluster Headache (Mostly men)Most severe pain ever lasting 30-120 minutesUnilateral, side-lockedAgitation, pacing (cf migraineurs prefer to keep still)Unilateral Cranial Autonomic features:-
tearing, red conjunctiva, ptosis, miosis, nasal stuffiness
Acute treatments: Sumatriptan injection 6mg s.c. (Contraind.: IHD and stroke)Hi-flow oxygen through a non-rebreathe bag and mask (10-12litres/min)Prednisolone 60mg o.d. for 1 week can abort a bout of attacks
2)
Analgesic/Triptan Overuse HeadacheOften mixture migraine and background headacheAnalgesic intake ≥15 days/month (opiates/triptans ≥10 days) for ≥3 consecutive monthsTreatment: stop analgesic and triptan for 2 months and follow up
Red Flags• Headache rapidly increasing in severity and frequency despite appropriate treatment.• Undifferentiated headache (not migraine / tension headache) or
new persistent daily headache of recent origin and present for >8 weeks
• Recurrent headaches triggered by exertion• New onset headache in:- >50 years old (consider giant cell arteritis) Patients with focal neurological signs or change in personality Immunosuppressed / HIV
4)Emergency Symptoms/signsThunderclap onset (i.e. max intensity in <5 mins)Accelerated/Malignant hypertensionAcute onset with papilloedemaAcute onset with focal neurological signsHead trauma with raised ICP headachePhotophobia + nuchal rigidity + fever +/-rashReduced consciousnessAcute red eye: ?acute angle closure glaucomaNew onset headache in:
•3rd trimester pregnancy/early postpartum•Significant head injury(esp. elderly/ alcoholics / on anticoagulants)
Giant Cell arteritis (Incidence 2/10,000/ year)•Think about it: New headache in >50 year old•Other headaches may briefly respond to high dose steroids, so do
not use response as the sole diagnostic factor.•ESR can be normal in 10% (check CRP as well)•Symptoms may include: jaw/tongue claudication, visual
disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudicationUrgent referral: rheumatology if GCA diagnosis suspected, ophthalmology or TIA clinic if amaurosis fugax / visual loss / diplopia (not migrainous auras!).
Patient in GP setting: Who to scan ?Basically, no-one who does not needreferring in needs a scan. However, ifa scan is being done for reassurance, aCT head scan will suffice.
5)
6)
Other headaches..Temporal arteritis >50yrsTrigeminal neuralgiaCervicogenicTMJ dysfunctionSinuses
Primary low pressure postural
Trigeminal Neuralgia• Usually V2 + V3• Sensitive, excruciating• First line treatment: Carbamazepine• Alternatives: gbp, pregabalin, oxcarbazepine,
amitriptyline, baclofen.• Who to refer?
o Uncertain diagnosis/atypicalo If do not respond to cbzo young
• Investigation – if needed o MRI – vasc loop, demyelination, compression
Conclusions• Headaches are very common• Migraine underdiagnosed• Most are benign but rare serious cause• Most can be managed in primary care• Refer in/advice and guidance if
o Unsure of diagnosiso Atypical featureso Inadequate response to treatment
• www.newcastle-hospitals.org.uk/neurogps
