I’ve got a headache

1. I’ve got a headache ??? Headache David Kernick Exeter Headache Clinic

2. Migraine impact • Headache in top 10 of WHO disability index. • 20% population – headache impacts on their quality of life (adults and children) • £3 billion per year in economic terms

4. When people come to see you what do they think they have?

5. When people come to see you what do they think they have? • Need glasses • Blood pressure • Brain tumour

6. What do patients have when they present to GP with headache?

7. What do patients have when they present to GP with headache? Landmark Study • 85% migraine • 10% Tension type headache • 5% secondary headache • <1% other types of headache

8. What do GPs think when patients present with headache?(Kernick 2008)

9. Headache consultations in primary care • Consultation rates are low. 50% of migraine sufferers have never seen a doctor • 10% are under continuing care • One third of headaches will be incorrectly diagnosed.

10. What is happening in primary care? • Less than 20% will receive Triptan Walling 2006 • 10% of those who would benefit from prevention receive it Rahimtoola 2005

11. Headache referral patterns • 9% GP presentations are referred to secondary care (25% children) (Loughey) • 20 - 30% of neurology referrals are for headache (Hopkins)

12. What do patients have when they present to A and E with headache? Valade 2000n – 9480Average age 37250 admitted (3%)

13. Migraine 55% • TTH 25% • Cluster 7% • Trauma 1.6% • Trig Neuralgia 1.6% • Sinusitis 1.6% • Vascular disorders 1.2% • Low Pressure 1.2% • Meningitis 0.35% • Tumour 0.17% • Other Misc < 5%

14. Case 1 • 35 year old male • Three week history • Sharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively. • One question? • Two examinations? • Would you investigate?

15. Classifying headache

16. Where does the pain come from?Intra – cranial (dural pain fibres) • Tension – raised intracranial pressure • Compression – tumour • Inflammation - migraine,meningitis,blood

17. Where does the pain come from?Extra - cranial • Arteritis • Neuralgia • Muscle tension • Facial structures

18. Migraine Tension type Autonomic cephalalgias (cluster) Traumatic Vascular Non-vascular (SOL) Substance induced Infection Disturbed homoestasis Facial structures IHS Headache classificationPrimary Secondary

19. Activation anywhere in the system can lead to output in any other part of the system and vici versa

20. AURA Medication overuse headache Thalamus + Mid Brain structures Tension type headache Hypothalamus CLUSTER CERVICAL NUCLEI MIGRAINE CENTRE Headache model Secondary Headaches Primary Headaches

21. Case 1 • 35 year old male • Three week history • Sharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively. • One question? • Two examinations? • Would you investigate?

22. Two examinations • Fundoscopy • BP • ‎Giles Elrington neurological examination ‎

23. Case 1 • 35 year old male • Three week history • Sharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively. • One question? • Two examinations? • Would you investigate?

24. Headache Pathway EXCLUDE A SECONDARY HEADACHE • Do something now • Do something soon • DIAGNOSE A PRIMARY HEADACHE • Exclude medication overuse and manage the primary headache

25. Case 2 You are called out to a 21 year old female who has had severe sudden onset headache. She is lying in a darkened room vomiting and is unable to move. What is the differential diagnosis?

26. Sub Arachnoid - thunderclap headache

28. Thunderclap headache - RVS • lasts 1-3 mths. • Primary or secondary • Normal CT, LP. Needs CT angio. • Can get complications

32. Meningitis

33. Malignant hypertension

34. Migraine - The emergency call out • Injectable sumatriptan • I.M. Diclofenac and anti-emetic • Avoid opiates • Sort out the migraine

35. Case 3 • 55 year old male. • New headache. L temporal. Fluctuating in intensity. Featureless. Examination normal. • What would you do?

36. Temporal arteritis • Can be bilateral • Systemically unwell • Tender artery with allodynia • CRP better than ESR • Problem with skip lesions

37. CASE 4 • 26 year old pole dancer • Headache with intercourse • What questions would you ask her? • Any investigations? • Treatment?

38. Sex headache • Pre orgasmic or orgasmic (10% SAH) • Primary or secondary (vascular, tumour, Arnold Chiari) • Low threshold for investigation • Treatment • Technique • B blocker • Indometacin • Avoid recreational drugs

39. Non specific headache • Tinnitus • Two examinations • What is most likely diagnosis?

40. Low Pressure Headache

41. Case 5 A 34 year old man presents with pain around his left eye that he describes like a “red hot poker”. He has had a number of attacks over the last few weeks. With this presentation, what are the key questions you need to ask him to establish a diagnosis? What investigation will you do?

43. Cluster - Autonomic Cephalopathy • High impact ++ • Peri-orbital clusters 15mins - 3 hours • Cluster attacks and periods • Unilateral autonomic features • Acute or chronic

44. Cluster treatment • Injectable Sumatriptan • Nasal Zolmitriptan • Short term steroids • Oxygen 100% • Verapamil

45. CASE 6 • 45 year old female • Dull continuous bilateral occipital pain • Featureless • Worried as friend had brain tumour and wants a scan • Three questions? • Do you investigate?

46. Have you ever had migraine? • Do you have problems with your neck? • What pain killers are you taking? • To scan or not to scan?

47. Withdrawal of all analgesia Increased frequency of headache, associated with increased frequency of analgesia use. Return of episodic headache Daily headache with spikes of more severe pain Medication overuse headache Headache intensity Migraine attacks Frequent ‘daily’ headaches

48. Primary Tumours • Meningioma 20% - 10 yr survival 80% • Glioma 70% - 5yr survival 20% • Misc. 10% - Variable

49. Headache and tumour • Headache prevalence with tumour 70%+ • Headache at presentation 50% • Headache alone at presentation 10% (Iverson 1987)

50. Risk of brain tumour with headache presenting to primary care (Kernick 2008)