Headache. Luke Bennetto Consultant Neurologist Engineers House 13 th September 2016
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1 Headache Luke Bennetto Consultant Neurologist Engineers House 13 th September 2016
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3 Contents General thoughts Primary headache Secondary headache
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5 I want to curl up in a cave and die
6 I want to drill a hole in my head
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8 Heads are very good at hurting they rarely need a good reason. Primary headache is very common. Secondary headache is rare. Brain tumour virtually never presents as headache to a secondary care adult neurology clinic
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11 International Classification of Headache Disorders IIIb I- Primary Headache 1. Migraine 2. Tension headache 3. Trigeminal Autonomic Cephalalgias Cluster Paroxysmal Hemicrania SUNCT/SUNA 4. Other Primary Headache Cough Exercise Sexual activity Thunderclap Cold stimulus Stabbing headache Exploding head Hypnic headache II - Secondary headache 5. Trauma 6. Cranial or cervical vascular 7. Intracranial non vascular 8. Substances 9. Infection 10. Homeostasis 11. Disorder head, neck, eyes 12. Psychiatric III Cranial neuralgias/ facial pain Trigeminal neuralgia Trigeminal neuropathy Glossopharyngeal Geniculate Occipital
12 The key to diagnosis in headache
13 Primary headache in secondary care Migraine Tension Cluster CPH SUNCT Idiopathic stabbing Hypnic Exploding head
14 There are more treatment options for migraine
15 How to turn tension into migraine What do you do (or want to do) when you get a headache? (Not does light bother you)
16 How to turn tension into migraine What was the headache like when it first started? No, think carefully did it come and go did you feel sick did you have to take painkillers regularly to stop the bad headaches
17 How to turn tension into migraine Does anyone in the family have bad headaches where they feel sick and have to go to bed?
18 When was your last headache free moment? Do painkillers help?
19 Migraine treatment Non pharmacological:
20 Migraine treatment Non pharmacological:
21 Migraine Treatment: Pharmacological Put the fire out early If infrequent then take analgesia as soon as you think I m not having a headache am I Dispersible aspirin/paracetamol 1g Consider anti-emetic to aid gastric absorption
22 Triptans No more effective than simple analgesia but work in some patients where simple analgesia ineffective. Preferable to opiates. Can combine with NSAIDs. Very safe. Triptan sensations. Sumatriptan, rizatriptan, zolmitriptan, naratiptan, almotriptan, frovatriptan.
23 Avoid narcotics at all costs
24 Educate about medication overuse Avoid painkillers on more than 2 days per week. NICE paracetamol/nsaids 15 days per month for 3 months NICE opiates/triptans 10 days per month for 3 months
25 Treating MOH/chronic migraine Stop analgesics (NICE) for 1 month. Consider preventatives Propanolol/Topiramate (NICE) Amitryptiline Valproate Pizotifen Botox
26 11. Start low and go slow
27 Modest goals (lower expectation) In chronic headache aim for 50% reduction in headache in 6 months. Impatience leads to effective medication being discarded too early Headache diary
28 Trigeminocervical complex 13. Trigemino-cervical complex
29 Trigeminal Autonomic Cephalalgia Cluster ( minutes) Paroxysmal Hemicrania (2-30 minutes) SUNCT/SUNA ( secs) All sidelocked
30 16. Best way to separate trigeminal neuralgia from TACs?
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32 Cluster vs Migraine?
33 Cluster treatment Sumatriptan injections 100% high flow oxygen Verapamil Occipital nerve injection
34 Indomethacin Powerful NSAID Switches off Chronic Paroxysmal hemicrania Suggest trying in patients with refractory side locked headache
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36 Trigeminal Neuralgia
37 Trigeminal neuralgia
38 Secondary headache
39 Thunderclap headache All headache is sudden onset SAH usually 5 minutes to maximal intensity (NICE) SAH usually greater than 24 hours. Can a primary or secondary headache syndrome be diagnosed? How often have they had it? How long does it last?
40 Other causes of thunderclap Migraine is the commonest SIH PRES Exploding head syndrome Hemicrania
41 Giant cell arteritis does not occur under the age of 50 Never Ever Or at least the risk of considering the diagnosis exceeds the benefits.
42 GCA can occur with normal Plasma Viscosity But almost certainly not with normal PVisc, CRP and platelets.
43 Idiopathic intracranial hypertension AKA ORICH Headache is their main concern Our main concern is visual loss Weight loss is the treatment
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48 Investigations CT Brain normal Routine bloods normal MRI Brain showed manky right middle ear. HIV negative Lyme/ACE and CXR normal CSF: Open. press.>40cm 0 WBCs, 10 RBCs Protein 0.48 g/l Negative OCBs Negative cytology
49 MRV Brain (Sagittal sinus)
50 Thank you for listening Questions?
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Ravishankar, et al: Headache disorders S41 emphasize that the primary physicians should know when to get a neuroimaging in a headache patient to rule out the secondary causes of headache. Also, they should
Back Pain. John W. Engstrom, MD December 15, Disclosures. A Primary Care Approach to Headache. Headache Goals
Disclosures Nothing to declare --- or --- Significant ownership interests Consulting, speaker bureaus, honorarium, grants Link to Harrison s Chapter on Headache: http://ucsfneuroresidency.com/public_html/educati
Classification of headaches
Classification of headaches Jasna Zidverc Trajković Headache center Headache in adults: 1-year prevalence 13.4 Kryst 35.9 Miranda 28.7 Jaillard 87.3 O Brien 63.1 Wiehe 37.3 Lavados 59.7 Schwartz 76.0 Boardman