Transcript Protected Teaching - Luton and Dunstable University Hospital

Headache
Headache
• Headache affects 75% of population per year (45
million people) and 25% of Neurology OP
referrals
• Daily headache affects 4% of population
• On any day 90,000 people are absent from work or
school because of headache
• Migraine alone accounts for 20 million lost work
or school days per year
• Cost of migraine to the economy in UK £1 billion
per year
Most headaches are due to:
• Tension-type headache 70%
• Migraine 14%
Classification of headache 1. Primary headache
(from IHS 2003)
(must have characteristic or benign features without abnormal
neurological signs)
1. Migraine
2. Tension-type headache
3. Cluster headache and other trigeminal
autonomic cephalgias
4. Other headache not associated with structural
lesion
Classification of headache 2. Secondary headache
(from IHS 2003)
5. Head or neck trauma
6. Cranial or cervical vascular disorders
7. Non-vascular intracranial disorders
8. Substances or their withdrawal
9. Infection
10. Disorder of homeostasis
11. Eye, ENT, orofacial, or cervical disorders
12. Psychiatric disorder
13. Cranial neuralgias and central causes of facial pain
14. Headache not classifiable
Migraine characteristics
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Attacks of headache lasting 4 to 72 hours
Nausea and/or vomiting
Intolerance of light
Intolerance of noise
Recurrent attacks
Visual or neurological aura lasting 6 – 60 mins
Consistent trigger
A few headache cases
Headache - Danger Signals
• First and worst headache
• Association with
– loss of consciousness or collapses
– non-migrainous visual disturbances or focal
neurological signs
– fever or rash
• Sudden headache with vomiting and/or loss of
consciousness at onset
• Neck stiffness
• Jaw claudication (pts over 50)
Headache - Concerning features
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New onset headache after age 50
Genuinely increasing frequency and severity
Waking patient from sleep
Unresponsive to treatment
Always on same side
Following head trauma
Precipitated by exertion
New headache in patients:
– On anticoagulants
– With HIV or cancer
Diagnosis
• Careful history
• Examination
– to exclude focal neurological signs or RIP
– evidence of anxiety, tension or depression
Diagnosis 1 – History
Careful attention to detail
• Recognition and assessment of each type of headache
• Details of onset, duration, pattern and progression. Nighttime headache
• Associated features
– Blackouts, collapses, jaw claudication, visual disturbances,
incontinence
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Triggers, aggravating and relieving factors
Effect on usual activities
Treatments tried
Lifestyle, work and home stress, anxieties
Other relevant medical history
Drugs, alcohol, medication
Diagnosis 2 - Examination
• Systemic disease, e.g. fever, BP, evidence of
cancer
• To exclude focal neurological signs or RIP
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Visual field loss
Papilloedema
Cranial nerve palsies especially 3rd and 6th
Lateralised limb weakness
Abnormal reflexes and extensor plantars
Ataxia
Abnormal gait
• Look for evidence of anxiety, tension or
depression
Investigations
• None may be necessary
• Investigation of systemic disease if
suspected
• ESR & CRP if GCA suspected
• Brain imaging
– if structural lesion suspected
– for reassurance (patient, relatives, doctor!)
Frishberg et al 1994 - The utility of neuroimaging in the
evaluation of headache in patients with normal neurological
examinations. Review of 23 studies
1.
Total scans
Tumour
AVM
Hydrocephalus
Aneurysm
Subdural haem.
Migraine
No.
%
897
100
3
0.3
1
0.1
Unspecified headache
No.
%
1825
100
21
1
6
0.3
8
0.4
3
0.2
5
0.3
Headache Literature
Elrington (1999) - 1000 headaches
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Ages
Tension-type headache
Migraine
Psychiatric (mainly depression)
Analgesic misuse
8 - 87
34%
26%
12%
9%
1
Headache Literature
Elrington (1999) - 1000 headaches
2
• Secondary headaches
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Mass lesion
SAH
Idiopathic intracranial hypertension
Giant cell arteritis
1% (11)
0.7%
0.2%
0.1%
• Clinical features predictive of abnormal imaging
– thunderclap headache
– papilloedema
– ataxia
AAN Guidelines on imaging in headache
1994
“In adult patients with recurrent headaches that have
been defined as migraine including those with
visual aura, with no recent change in pattern, no
history of seizures and no other focal neurological
signs and symptoms, the routine use of
neuroimaging is not warranted. In patients with
atypical headache patterns, a history of seizures or
focal neurological signs or symptoms, CT or MRI
may be indicated.”
Indications for referral?
1. Where specialist diagnosis is required
2. Clincal features suggest significant or
serious neurological disease
3. Failure to respond to appropriate adequate
treatment
4. Patient at high risk of serious disease
5. Reassurance
Indications for referral
1. Where specialist diagnosis is required
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Unclear clinical features
Imaging required
2. Clincal features suggest significant or serious neurological disease
1.
2.
3.
Progressive or sinister headache symptoms
Associated neurological symptoms (e.g. seizures, blackouts,
collapses)
Abnormal neurological signs
3. Failure to respond to appropriate adequate treatment
4. Patient at higher risk of serious disease
1.
2.
Cancer patients
New headache in older patients
5. ?reassurance
Where to refer?
A&E/ACU
Headache Clinic
Neurology Clinic
Very short history
suggesting
catastrophic or acute
life-threatening
disease. e.g
meningitis, SAH,
ICH, encephalitis
Diagnosis and advice
on management in
primary care of
patients whose main
problem is headache
Diagnosis and
management of
patients with primarily
neurological diseases
who cannot be
managed in primary
care
Headache Clinic
Headache Clinic
581 patients
Migraine
199 (34%)
Tension-type
229 (39%)
Cluster
16 (3%)
Analgesic misuse
34 (6%)
Other non-structural
14 (2%)
Trauma
5 (1%)
Vascular
5 (1%)
*Non-vascular intracranial
disorders (incl tumours)
5 (1%)
Face, Neck, Ears, Neuralgias
7 (1%)
Non-classifiable
12 (2%)
Headache Clinic 581 patients
Non-vascular intracranial disorders
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Intracranial tumour
BIH
Aqueduct stenosis
Other
1
2
1
1
What is the outcome of
investigation?
• Headache Clinic
• CT
• Relevant abnormality
581 patients
239
2
Management of Tension-Type
Headache and Migraine
Management
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Accurate diagnosis
Clear explanation
Discuss environmental factors
General advice
– diet, coffee, alcohol, lifestyle, use of analgesics
– Stress and anxiety management
– relaxation
• Specific treatment
Management of Tension-type headache
• Lifestyle issues
– work-home-leisure
balance
– exercise
– sleep
• Physical measures
– relaxation
– physio
– self-help
• Drugs
– limited simple
analgesics
– amitriptyline
– SSRIs
– others
“Wolcott’s instant pain
annihilator”
Acute attacks of Migraine
• Early analgesics
– Aspirin 600-900mg
– Ibuprofen 400mg
– Paracetamol 1G
• Analgesics plus antiemetics
– Metoclopramide
– Buccastem
• Triptans
– Rizatriptan 10mg
– Almotriptan 121.5mg
– Eletriptan 40-80mg
Prevention of Migraine
• Consider if 2 or more attacks per month
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Beta-blockers
Pizotifen
Amitriptyline
Venlafaxine
Valproate
Topiramate
Gabapentin
Headache Guidelines
• www.bash.org.uk
• www.sign.ac.uk