Managing Headache in Acute Medicine. Ben Lovell Consultant Physician in Acute Medicine University College London Hospital

Transcription

1 Managing Headache in Acute Medicine Ben Lovell Consultant Physician in Acute Medicine University College London Hospital

2 Some ED headache stats Arrive by ambulance 31% Median age 39 Worst ever headache 37% 10/10 severity 23% Instant peak 18% Max intensity <1 hour 44%

3 Some ED headache stats GCS <15 4% Associated with neck stiffness 4.8% Get a CT head 38% Get an LP 4.7%

4 How to assess a headache 1. Assess for serious secondary causes 2. Assess for non-serious secondary causes 3. Assess for tension-type headache and migraine 4. Consider for less common causes of headache

5 Serious secondary causes Raised ICP SOL or IIH Infective Fever/meningism Malignancy elsewhere Bleeding GCA if >50 Following trauma Neurological impairment Thunderclap

6 Thunderclap headaches About 50% of thunderclap headaches are not 6% of thunderclap headache are due to SAH 12% of SAH are missed on first presentation Kowalski RG, Claassen J, Kreiter KT et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 2004;291: The Ottawa rule Perry et al. Clinical Decision Rules to Rule Out Subarachnoid Hemorrhage for Acute Headache. JAMA. 2013;310(12): patients with thunderclap headache

7 The Ottawa rule Sensitivity = 100% (no false negatives) Specificity = 17.8% (lots of false positives)

8 Implications of Ottawa Rule If people screen negative they do not require investigation for SAH If people screen positive, they may have SAH and require investigation

9 So who needs LP? Perry Jeffrey J, Stiell Ian G, Sivilotti Marco L A, Bullard Michael J, Émond Marcel, Symington Cheryl et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study BMJ 2011; 343 :d4277 Have SAH Don t have SAH CT positive CT negative Sensitivity = 92.9% (few false negative CT scans) Specificity = 100% (no false positive CT scans)

10 So who needs LP? Perry Jeffrey J, Stiell Ian G, Sivilotti Marco L A, Bullard Michael J, Émond Marcel, Symington Cheryl et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study BMJ 2011; 343 :d4277 > 6 hours after headache onset Have SAH Don t have SAH CT positive CT negative Sensitivity = 85.7% Specificity = 100%

11 So who needs LP? Perry Jeffrey J, Stiell Ian G, Sivilotti Marco L A, Bullard Michael J, Émond Marcel, Symington Cheryl et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study BMJ 2011; 343 :d4277 < 6 hours after headache onset Have SAH Don t have SAH CT positive CT negative Sensitivity = 100% Specificity = 100%

12 GCA 0.02% of > 50 year olds Mean age of onset is 75 Usually women (8:1) Diagnosis 4% have normal ESR ESR may be suppressed by Statins Anti-inflammatories DMARDS

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14 American College of Rheumatology > 3 of the following: Age >50 New headache Temporal artery tenderness or loss of pulsation ESR>50 Abnormal temporal artery biopsy Sensitivity = 94%, specificity = 91%

15 Treatment Shoot first and ask questions later Biopsy results remain abnormal 7 days post steroid treatment

16 RCP guidelines

17 How to assess a headache 1. Look for symptoms of serious secondary causes 2. Assess symptoms of non-serious secondary causes 3. Assess for tension-type headache and migraine 4. Consider for less common causes of headache

18 Non-serious secondary causes Medication-overuse headache Generalised fever Sinusitis Otitis media Dental abscess TMJ dysfunction

19 Medication Overuse Headache Criteria Pre-existing primary headache disorder Pain for >15 days/month >3 months Regular analgesia taken COMMON

20 Medication Overuse Headache Treatment Education (76% cured at 18 months) Detoxification Effective treatment of primary headache Relapse is common

21 Medication Overuse Headache TAY AWAY FROM OPIOIDS

22 How to assess a headache 1. Look for symptoms of serious secondary causes 2. Assess symptoms of non-serious secondary causes 3. Assess for tension-type headache and migraine 4. Consider for less common primary causes of headache

23 Migraine Criteria (ICHD 2013) Lasts between 4 hours - 72 hours Has 2 out of the following: Unilateral Pulsating Moderate to severe Aggravated by physical activity At least 5 attacks! Has 1 out of the following: Nausea/vomiting Photophobia/phonophobia

24 Migraine POUND criteria Pulsatile One day duration Unilateral 4 or more features = 92% likelihood of migraine Nausea/vomiting Disabling Wilson JF. In the clinic. Migraine Ann Intern Med 2007;147(9): ITC11-1 ITC11-16

25 Prodrome Aura phase Migraine 60% of sufferers 2-24 hours Mood change, body aches, change in bowel habit One third migraineurs Less than 1 hour Mood change, body aches, change in bowel habit Pain phase 4-72 hours Associated with nausea, vomiting, phono/photophobia Postdrome

26 Mathur V et al. ecollection High Frequency Migraine Is Associated with Lower Acute Pain Sensitivity and Abnormal Insula Activity Related to Migraine Pain Intensity, Attack Frequency, and Pain Catastrophizing.Front Hum Neurosci Sep 29;10:489

27 Acute migraine It is crucial to: Intervene early, when the pain is still mild Use adequate drug doses and appropriate routes of administration Antiemetic or prokinetic drugs should be co-administered to facilitate absorption of the primary drug Take steps to avoid chronification of the headache and the development of MOH Antonaci F, Ghiotto N, Wu S, Pucci E, Costa A. Recent advances in migraine therapy. SpringerPlus. 2016;5:637. doi: /s

28 Opioids NICE: Opioids are not recommended because they may exacerbate nausea and will also increase the risk of medication overuse headache. BASH Narcotics are NOT recommended for the emergency treatment of migraine and their use can be associated with delayed recovery

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30 Non-specific treatments Paracetamol NNT =12 NSAIDS Aspirin 900mg Ibuprofen/diclofenac/naproxen IV fluid Mixed evidence Dehydration is a known trigger for migraine Patients with migraine often become dehydrated

31 Specific treatments Triptans 5-HT1B/1D receptor agonists Inhibit neurotransmitter release at both peripheral and central trigeminal nociceptive terminals Aborts migraine attack in 80%

32 Side effects Triptan sensations Flushing Paraesthesia Chest pressure Vasoconstriction, therefore C/I in: Uncontrolled HTN CAD Raynaud s

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34 TTH Lasts 30 mins - 7 days, and has 2 of the following: Bilateral Pressing/tightening Mild to moderate intensity Not aggravated by activity Does not cause nausea/vomiting, but may have photo/phonopobia

35 Paracetamol 1000 mg may relieve headache pain, but the chance of the pain being relieved entirely by two hours is low, about 2 in 10 (24%), but this is only very slightly greater than the proportion who took placebo (about 1 in 5, or 19%)

36 NICE guidelines Listen to and address the person's concerns about their symptoms. Treat acute tension-type headache (TTH) with paracetamol, aspirin, or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen. Advise people that the overuse of painkillers (prescribed or overthe-counter) can lead to medication overuse headache. Do not treat acute TTH with opioids or triptans.

37 Long term management There is no evidence for: SSRI Botulism toxin Homeopathy Beta-blockers There is weak evidence for acupuncture There is good evidence for: Amitriptyline Regular exercise

38 How to assess a headache 1. Look for symptoms of serious secondary causes 2. Assess symptoms of non-serious secondary causes 3. Assess for tension-type headache and migraine 4. Consider for less common causes of headache

39 Trigeminal autonomic cephalalgias Unilateral (1/3 sidelocked headaches) Trigeminal autonomic features: Tearing Conjunctival injection Nasal stuffiness Eyelid drooping Agitated patients

40 Trigeminal autonomic cephalgias A family of 5 headaches: Cluster headache SUNCT SUNA Paroxysmal hemicrania Hemicrania continua

41 Cluster headache High flow oxygen (15L via NRBM) results in 70% patients pain free at 15 mins Cohen AS et al. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA 2009; 302(22): Sumatriptan (sc) aborts the attack in 50%, and minimises pain in 75% Law S et al. Triptans for acute cluster headache. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD Analgesics have no place in the treatment of cluster headache - BASH 2010

42 Take home messages Opioids have (almost) no role in managing headache Always exclude secondary causes first The Ottawa rule and 6-hour rule makes your management of?sah much more straightforward Be alert for the trigeminal autonomic cephalgias