HEADACHEDr Nick PendletonMarch 2015

Headache• Tension Type Headache• Cranial Nerve Examination• Migraine• Migraine Treatment• Medication Overuse Headache• Headache Red Flags• Sinusitis Headache• Raised ICP Headache• Acute Severe Headache

Small Group Work• Tension Type Headache• Cranial Nerve Examination• Migraine• Migraine Treatment• Medication Overuse Headache• Headache Red Flags• Sinusitis Headache• Raised ICP Headache• Acute Severe Headache

NICE GUIDELINE CG150

Diagnosis and Management of Headaches in Young People and Adults

https://www.nice.org.uk/guidance/cg150

DIAGNOSTIC CRITERIA FOR TTH

(A)At least 10 episodes fulfilling the criteria B-D:

(B) Headache lasting from 30 minutes to 7 days(C) Headache has at least two of the following characteristics:Bilateral locationPressing/tightening (non-pulsating) qualityMild or moderate intensityNot aggravated by routine physical activity such as walking or

climbing stairs(D) Both of the following:No nausea or vomiting (anorexia may occur)No more than one episode of photophobia or phonophobia(E) Not attributable to another disorder

Patient with Tension-Type Headache indicating location of his headache pain.

Loder E , Rizzoli P BMJ 2008;336:88-92©2008 by British Medical Journal Publishing Group

DIAGNOSTIC CRITERIA FOR TTH

Infrequent episodic tension-type headacheDiagnosed if headaches meeting the above criteria occur <1 day a month (<12 days a year) on average

Frequent episodic tension-type headacheDiagnosed if headaches occur >1 and <15 days a month (>12 and <180 days a year).

Chronic tension-type headacheDiagnosed if headaches occur ≥15 days a month (180 or more days a year).

RED FLAGS• Onset of new or different headache• Nausea or vomiting• Worst headache ever experienced• Progressive visual or neurological

changes• Paralysis• Weakness, ataxia or loss of co-

ordination• Drowsiness, confusion, memory

impairment or loss of consciousness• Onset of headache after age of 50 years

More RED FLAGS

• Symptoms/Signs of Papilloedema• Stiff neck• Onset of headache with exertion, sexual

activity or coughing• Systemic illness• Numbness• Asymmetry of pupillary response • Sensory loss• Signs of meningeal irritation

Link to Article about Red Flags

• http://www.gponline.com/red-flag-symptoms-headaches/neurology/headache-migraine/article/1332134

MIGRAINE

Migraine• Repeated attacks of headache lasting 4–72

hours that have these features :• A: Normal physical examination• B: No other reasonable cause for the headache• C: At least two of: Unilateral pain• Throbbing pain, Aggravation of pain by

movement, Moderate or severe intensity of pain

• D: At least one of Nausea or Vomiting• Photophobia and phonophobia

MIGRAINE WITH AURA

• 20–30% experience migraine with aura• Focal neurological phenomena that

precede the attack• Appear gradually over 5 to 20 minutes

and generally last fewer than 60 minutes• Headache phase usually begins within 60

minutes of the end of the aura phase.

AURA

• Common aura symptoms include:• Visual disturbances (such as

flashing/flickering lights, zigzag lines and even temporary blindness)

• Numbness, tingling sensations and slurred speech.

• Other aura symptoms include a stiff neck, weakness on one side, partial paralysis, confusion or fainting

Migraine, Stroke and the OCP

• Patients who have Migraine with Aura are at increased risk of ischaemic stroke

• Giving these patients an OCP increases this risk significantly

• + Hypertension• + Smoking• + age > 35

Some figures: • In Women under 35:

• those who do not have migraine and do not take the pill (i.e. the background risk): 1.3 per 100,000 women per year are at risk of stroke

• those who have migraine without aura but don’t take the pill: 4 per 100,000 women per year at risk of stroke

• those who have migraine with aura but don’t take the pill: 8 per 100,000 women per year are at risk of stroke

• those who don’t have migraine and take the pill: 5 per 100,000 women per year at risk of stroke

• those who have migraine with aura and take the pill: 28 per 100,000 women per year at risk of stroke

• those who have migraine without aura and take the pill: 14 per 100,000 women per year are a risk of stroke

http://www.migrainetrust.org/factsheet-stroke-and-migraine-10891

Treatments for Migraine• Triptans, selective 5-HT1B/1D receptor agonists –various

formulations & types• Ergot derivatives (older treatment, not commonly used)• Antiemetics & nsaids

Preventative : 2/3 will have 50% reduction• Many have significant side effects:• Pizotifen – weight gain, drowsiness• B- Blockers – tiredness• Tricyclics – drowsiness• Anticonvulsants – valproate, topiramate, gapapentin –

significant s/e. Botulinum Toxin type A http://www.nice.org.uk/guidance/ta260

• Candesartan : http://www.ncbi.nlm.nih.gov/pubmed/24335848

Medication Overuse Headache

• Headache present on at least 15 days per month

• Developed or markedly worsened during medication overuse

• Headache resolves or reverts to its previous pattern within two months on discontinuation

• Regular overuse for three months or more

Culprits

• Opiates, codeine +/- paracetamol• 10 days+ per month

• Triptans or NSAIDs• 15 days+ per month

Vicious Cycle

• Bad spell of headaches eg stress• Take more painkillers• Body gets used to medication• Rebound/withdrawal if stop for>1d• Think this is another usual

headache• Take more painkillers• Problem worsens

Blood Pressure and Headache

• Very High BP can cause Headache

• Patients will Expect to have BP checked when presenting with Headache

• Children with Headache – check BP

• 3rd Trimester Pregnancy and Headache ?Pre-eclampsia

SINUSITIS HEADACHE

Headache worse on lying downNasal congestionNasal discharge purulent +/- bloodCough, Fever, MalaiseTender at point of painCan be unilateralTreatment:

http://bjgp.org/content/63/616/611

RAISED ICP

• New increasing headache• Present on waking• Increased by stooping or straining• Changes in mental state• Vomiting• Papilloedema• Causes: sinister and benign, acute and

chronic

Idiopathic Intracranial Hypertension

• Link to Excellent summary:

• http://www.patient.co.uk/doctor/idiopathic-intracranial-hypertension-pro

SAH• Risk factors similar to stroke eg. Smoking,

hypertension• Family History in 5-20%• Incidence 6 cases per 100,000 patient yrs• 50% fatality, 1/3 remain dependent• Sudden explosive headache is the

cardinal feature.• If related to sexual intercourse ?SAH• CT scanning is mandatory in all, to be

followed by (delayed) lumbar puncture if CT is negative

SAH

• A period of unresponsiveness of >1 h occurs in almost half of patients

• Focal signs develop at the same time as the headache or soon afterwards in one third of patients

• Classically, the headache from aneurysmal rupture develops in seconds, but can be minutes

SAH

• Vomiting occurs in 70% of patients• Neck stiffness is a common sign in SAH of any

cause, but takes hours to develop and therefore cannot be used to exclude the diagnosis if a patient is seen soon after the sudden-onset headache

• If thunderclap headache is the only symptom then 10% only will have SAH, but all need investigation

JULIE JONES, 45TELEPHONE TRIAGE CONSULTATION (Dr A)• Headache: started 3 days ago gradual onset worse

last night• Started to feel nauseous with it yesterday• Analgesia does help• Global but more at front left• Slight dizziness with nausea no vomiting or visual

disturbance of gross neurological symptoms• Suggested comes in for examination but most likely

tension type headache

Fictional name and age for illustration

JULIE JONES, 45FY2 CONSULTATION IN SURGERY (same day)• 3/7 tension like headache, frontal. No

photophobia• Vomited 3x overnight• Very stressed with work• Had tension and migraines in the past• Helped when lying down• Not worse bending over• No visual symptoms

JULIE JONES, 45• Unlikely to be pregnant - partner has had

vasectomy. D/W Dr B• Ibuprofen and paracetamol helped marginally• o/e PEARL, no focal tenderness, appears

anxious• Discussed stress at work and sleep hygeine• Advised to return if problem persists or

deteriorates

JULIE JONES, 45• DISCHARGE LETTER Hosp to ITU (1 week later)• Collapsed that evening and had seizure• Intubated and ventilated• Platelet count 6• Discussed with Haematology• Diagnosis TTP• To Have Plasma Exchange in Liverpool

JULIE JONES, 45Edited Highlights:• Had 3 cardiac arrests, Had plasma exchange• Discharged after 3 weeks• Medication started: Phenytoin, Prednisolone,

Aspirin, Gliclazide• Haematology follow up, Platelet count

recovered• Steroids reduced, gliclazide stopped• Driving: notify DVLA. Cannot drive for 6

months

LEARNING POINTS?

UPCOMING SESSIONS

17th March – Women’s Health (Dr Helen Wall)

21st April – Genetics (Dr David Harniess)