managing headache in acute medicine

Managing Headache

in Acute Medicine

Ben LovellConsultant Physician in Acute Medicine

University College London Hospital

Some ED headache stats

Arrive by ambulance 31%

Median age 39

Instant peak 18%

Max intensity <1 hour 44%

“Worst ever” headache 37%

23%10/10 severity

Some ED headache stats

GCS <15 4%

Associated with neck stiffness 4.8%

Get a CT head 38%

Get an LP 4.7%

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

Serious secondary causes

• Raised ICP

• SOL or IIH

• Malignancy elsewhere

• Bleeding

• Following trauma

• Neurological impairment

• Thunderclap

• GCA if >50

• Infective

• Fever/meningism

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;291:866–9.

• The Ottawa rule

• Perry et al. Clinical Decision Rules to Rule Out Subarachnoid Hemorrhage for Acute Headache.

JAMA. 2013;310(12):1248-1255

• 2321 patients with thunderclap headache

The Ottawa rule

Sensitivity

= 100%(no false negatives)

Specificity

= 17.8%(lots of false

positives)

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

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 223 0

CT negative 17 2892

Sensitivity = 92.9% (few false negative CT scans)

Specificity = 100% (no false positive CT scans)



study BMJ 2011; 343 :d4277

> 6 hours after

headache

onset


CT positive 102 0

CT negative 17 2060

Sensitivity = 85.7%

Specificity = 100%



study BMJ 2011; 343 :d4277

< 6 hours after

headache

onset


CT positive 121 0

CT negative 0 832

Sensitivity = 100%

Specificity = 100%

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

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%

Treatment

• ‘Shoot first and ask questions later’

• Biopsy results remain abnormal 7 days post steroid

treatment

RCP guidelines


1. Look for symptoms of serious secondary causes

2. Assess symptoms of non-serious secondary causes



Non-serious secondary

causes

• Medication-overuse

headache

• Sinusitis

• Dental abscess

• Generalised fever

• Otitis media

• TMJ dysfunction

Medication Overuse

Headache

• Criteria

• Pre-existing primary headache disorder

• Pain for >15 days/month

• >3 months

• Regular analgesia taken

• COMMON

Medication Overuse

Headache

• Treatment

• Education (76% cured at 18 months)

• Detoxification

• Effective treatment of primary headache

• Relapse is common

Medication Overuse

Headache

STAY AWAY FROM OPIOIDS



2. Assess symptoms of non-serious secondary causes


4. Consider for less common primary causes of

headache

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

• Has 1 out of the following:

• Nausea/vomiting

• Photophobia/phonophobia

At least 5

attacks!

Migraine

• POUND criteria

• Pulsatile

• One day duration

• Unilateral

• Nausea/vomiting

• Disabling

4 or more features =

92% likelihood of

migraine

Wilson JF. In the clinic. Migraine Ann Intern Med 2007;147(9): ITC11-1–ITC11-16

• Aura phase• One third migraineurs

• Less than 1 hour

• Mood change, body aches, change in bowel habit

Migraine

• Pain phase• 4 - 72 hours

• Associated with nausea, vomiting, phono/photophobia

• Postdrome

• Prodrome• 60% of sufferers

• 2 - 24 hours

• Mood change, body aches, change in bowel habit

Mathur V et al. eCollection 2016. 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. 2016 Sep 29;10:489

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:10.1186/s40064-016-2211-8.

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”

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

Specific treatments

• Triptans

• 5-HT1B/1D receptor agonists

• Inhibit neurotransmitter release at both peripheral and central

trigeminal nociceptive terminals

• Aborts migraine attack in 80%

Side effects

• ‘Triptan sensations’

• Flushing

• Paraesthesia

• Chest pressure

• Vasoconstriction, therefore C/I in:

• Uncontrolled HTN

• CAD

• Raynaud’s

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

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%)

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 over-

the-counter) can lead to medication overuse headache.

• Do not treat acute TTH with opioids or triptans.

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



2. Assess symptoms of non-serious secondary

causes



Trigeminal autonomic

cephalalgias• Unilateral (1/3 sidelocked headaches)

• Trigeminal autonomic features:

• Tearing

• Conjunctival injection

• Nasal stuffiness

• Eyelid drooping

• Agitated patients

• A family of 5 headaches:

• Cluster headache

• SUNCT

• SUNA

• Paroxysmal hemicrania

• Hemicrania continua

Trigeminal autonomic

cephalgias

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): 2451-2457.

• 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.: CD008042.

“Analgesics have no place in the treatment of

cluster headache” - BASH 2010

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

managing headache in acute medicine

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