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Serious Causes

Recognize the red flags in headache history for serious causes like thunderclap headache, new onset in different age groups, persistent morning headache, and association with cancer or HIV. Learn about urgent referral protocols and treatment options for migraines.

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Serious Causes

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  1. Serious Causes Rarely seen, but not to be missed

  2. Warning features in the headache history that suggest a serious underlying cause: Headache that is new or unexpected in an individual patient

  3. Thunderclap headache (intense headache with abrupt or “explosive” onset Patients with sudden severe (thunderclap) headache should be referred urgently when there is a suspicion of subarachnoid haemorrhage (SAH). Urgent out-patient referral is rarely appropriate as the majority of these patients require immediate investigation (normally a CT brain scan and lumbar puncture) to exclude SAH.

  4. Headache with atypical aura (duration >1 hour, or including motor weakness)

  5. Aura occurring for the first time in a patient during use of combined oral contraceptives

  6. New onset headache in a patient older than 50 years

  7. New onset headache in a patient younger than 10 years

  8. Persistent morning headache with nausea

  9. Progressive headache, worsening over weeks or longer

  10. Headache associated with postural change

  11. New onset headache in a patient with a history of cancer

  12. New onset headache in a patient with a history of HIV infection.

  13. Patients with other suspected serious causes of headache should be referred for an urgent appointment to the Neurology department. Very urgent referrals (e.g. suspected brain tumour referrals) should be discussed with the Neurology Specialist Registrar on-call to arrange an out-patient review.

  14. Treatment of Migraine • Acute Treatment for migraine headaches • First line: • high dose soluble Aspirin (900mg) combined with anti-emetic • Diclofenac 100mg suppository • Second line: Oral triptan (e.g. Almotriptan 12.5mg) • Migraine prophylaxis • First line: • Propranolol SR 80mg od-160mg bd • Amitriptyline 50-75mg/day • Second line: • Sodium Valproate 300-1000mg bd • Topiramate 50-100mg/day

  15. Medication-overuse Headache (MOH) • Only treatment is withdrawal of the suspected medication(s) • Triptans and Non-Opioid medications can be stopped abruptly • Opiates, opioids and barbiturates have to be withdrawn slowly • Withdrawal headache can be treated in the short-term with Naproxen 500mg bd

  16. Referrals for Chronic Migraine • Patients should be referred: • If there is concern about the diagnosis • If Migraines have not responded to adequate trial of treatment with at least two first-line agents • If there is continued headache despite withdrawal of analgesics likely to be causing medication-overuse headache • If there is severe uncontrolled migraine lasting more than 72 hours (status migrainosus) • Patients should be asked to keep a headache diary and identify trigger factors where possible.

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