Stuart Weatherby Consultant Neurologist Derriford Hospital. Plymouth

Transcription

1 Stuart Weatherby Consultant Neurologist Derriford Hospital. Plymouth

2 What is chronic headache? What are the causes? Why do people get headaches anyway? Why are there different sorts of headache? A model to explain why headaches occur Should I have a brain scan? A model to explain why there are so many treatments Avoiding things that might be harmful, incl medication overuse Factors predicting why pain becomes chronic How to improve things

3 Patient numbers PREVALENCE OF NEUROLOGICAL DISEASE IN USA 40,000,000 35,000,000 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 0 Disorders

4 3% of a GP s registered adult population will consult for headache each year and 7-9% of headache consultations will result in a referral to secondary care. Boardman H, Thomas E, Croft PR, Millson DS, Epidemiology of headache in an English district. Cephalalgia 2003;23: Headache on 15 days/month or more 5% of the population have daily or near daily headache Chronic Daily headache is not a diagnosis and doesn t imply a cause Chronic relates to the amount of the pain from Greek Kronikos = of time

5 I have been searching for answers for 17 years... the list of treatments and meds (both conventional and alternative) is huge I try not to talk about the headaches; they must bore other people. Another problem I have is a friend who I had to cancel a lunch date who is now irritated with me. I ve thought several times about calling her, but realize I don t have the energy to do it, and keep reminding myself that it s HER issue, not really mine. I just can t feel any more guilty. I have to fight it all the way Luckily, I have some very good, headache free days that reassure me that I m not lazy not trying to be manipulative by being sick not trying to get attention in a negative way etc. The first thing on my mind when I do anything is the pain. If I go out to dinner, will the restaurant be so loud that I can t handle it and will have to leave

6 50% of women and 40% of men account for 90% of time lost from work

7 How often have headache- how many days and how many have significant disability (eg grade 0-10) Effect on life Variability- what are the worst attacks like and how often Diary- to look for a pattern Triggers Family history Medication tried in the past- what, how long, what dose, when and why stopped Analgesic overuse

8 The changes in the brain in migraine are complicated Treatments should improve the symptoms by changing the pain systems and leave the rest of the brain alone

9 What causes Headache? Migraine

10 TRIGGER Pressure- generalised or specific on nerves CHRONICITY Depression (in 30-65% pts with CDH Fear CHRONICITY Medication overuse Tiredness Way built Stress- change Menstrual Change in pressure TRIGGER Infection Dietary Cheese Chocolate Alcohol etc? What

11 Pressure on a nervesharp shooting pain- TGA/can be chemical too Hypersensitivitynoise, light, smell etc Slowed thinking Aura Autonomic

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15 For virtually all patients with chronic daily headache Migraine is due to chemical changes not structural changes The risks of finding a relevant abnormality on a brain scan is no greater than chance. If the doctor requests a scan they are most likely being extra cautious but expect everything to be fine. Most patients with headache do not need a scan.

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18 TRIGGER Pressure- generalised or specific on nerves CHRONICITY Depression (in 30-65% pts with CDH Fear CHRONICITY Medication overuse Tiredness Way built Stress- change Menstrual Change in pressure TRIGGER Infection Dietary Cheese Chocolate Alcohol etc? What

19 Take chemicals that make the brain less sensitive to the chemical changes that produce headache- ie medicines They often are nerve membrane stabilisers, or act on other chemical triggers- eg female hormones Use other treatments that make the brain less sensitive to the chemical changes that produce headache- eg influence by changing the way the brain deals with pain chemicals eg acupuncture, psychological techniques

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22 Mechanism is unclear:- Repeated attacks of migraine- central sensitisation of trigeminal-pain pathways Overuse of analgesics- may sensitise central pain pathways Overuse of caffeine is a risk factor Problems sleeping a risk factor More common if depressed

23 Fear central role in the duration of pain Through medial prefrontal region, ventral lateral frontal region, and cingulate regions Anxiety and depression may also be markers for CNS chemical changes that play a significant role in the durability of pain. Between 30-50% of people with chronic daily headache can become depressed Catastrophizing was more than 7 times more powerful a predictor than any other predictor or clinical variable among acute back pain patients in determining the risk of subsequent chronic pain

24 Cognitive Interventions hysiological ensations Thoughts (Cognitions) Emotions Adaptive Behaviour Identification of stressful situations Negative thoughts and emotions fear of headache, repeated experiences - Catastrophising etc.. Identification and modifying cognitions will mediate stressheadache relationship. Consequence

25 CBT focuses on preventing mild pain from becoming disabling pain, improving headacherelated disability, affective distress, and quality of life, and reducing overreliance on medication. (Lipchick and Nash, 2002)

26 The Physician shall take a crocodile made of clay with sacred grain in its mouth. He shall bind it to the head of the patient with a strip of fine linen on which is written the names of the Gods

27 Diagnostic criteria A Headache present on >15 days per month B Regular overuse for > 3 months of acute symptomatic drugs Ergotamine, Triptans, opiods, OR combination analgesis 10 or more days / month Simple analgesic or any combination of the above on 15 or more days/month Headache developed or worsened during medication overuse

28 TRIGGER Pressure- generalised or specific on nerves CHRONICITY Depression (in 30-65% pts with CDH Fear CHRONICITY Medication overuse Tiredness Way built Stress- change Menstrual Change in pressure TRIGGER Infection Dietary Cheese Chocolate Alcohol etc? What

29 Shortest for triptans- 1.7 years Ergot 2.7 years Analgesics 4.8 years Can be difficult to be know whether the overuse of acute headache medication is the cause or consequence of CDH If the episodic pattern recurs within 2 months after drug withdrawal MOH is diagnosed

30 Investigation of renewed effect of prophylaxis. Danish Headache centre 175 pts with MOH from their cohort Former prophylactic non-responders had 49% decrease in headache frequency 88 pts didn t respond to complete drug withdrawal, subsequently improved with prophylaxis 26% improvement in headache frequency

31 What is chronic headache? What are the causes? Why do people get headaches anyway? Why are there different sorts of headache and different symptoms A model to explain why headaches occur Should I have a brain scan? Chronicity:- Incorrect diagnosis- increase awareness Incorrect treatment- make sure you get it Anxiety/Depression- if this is a factor tackle it (it goes both ways) Medication overuse- stop it,

32 TRIGGER Pressure- generalised or specific on nerves CHRONICITY Depression (in 30-65% pts with CDH Fear CHRONICITY Medication overuse Tiredness Way built Stress- change Menstrual Change in pressure TRIGGER Infection Dietary Cheese Chocolate Alcohol etc? What

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