Primary Headache Diagnosis RCGP 28.4.2009

1. Primary Headache DiagnosisRCGP 28.4.2009 Dr David PB Watson GPwSI Headache Hamilton Medical Group Aberdeen

2. Primary Headaches • Tension Type headache • Migraine • Trigeminal Autonomic cephalalgias • Others

3. Primary headache No underlying medical cause: Secondary headache Underlying medical cause: • Episodic primary headaches • Chronic primary headaches • Tumour • Meningitis • Vascular disorders • Systemic infection • Head injury • Drug-induced Headache types

4. Migraine Episodic primaryheadaches Probable Migraine Tension-type headache (TTH) TACs Episodic primary headaches

5. Diagnosis is by history, history, history • T timing • O other associated symptoms • S site • S severity • I influences aggravating/relieving factors • T type: what it feels like

6. Key points • Episodic disabling headache is migraine • Over diagnosis of sinus headache and TTH • 40% migraineurs miss ICHD-II criteria

7. Abbreviated diagnostic checklist based on IHS 2004 criteria Probable migraine Migraine Tension-type • Recurrent • No organic disease • Duration 4-72 h • Unilateral • Pulsating • Moderate / severe • Aggravated by movement • Nausea / vomiting • Photo / phonophobia • Recurrent • No organic disease • Duration 4-72 h • Moderate / severe • + one other • Recurrent • No organic disease • Duration 0.5 h-7 days • Generalised • Pressure / tightness • Slight / moderate • Photo / phonophobia Essential (3) Essential (2) Essential (1) Essential (3) = all items essential for diagnosis; Essential (2) = two items from list essential for diagnosis; Essential (1) = one item from list essential for diagnosis IHS 2004

8. Migraine • Epidemiology • 6 million people in the UK • Women 3x men • Most sufferers 20 to 50 • High impact • WHO disability • Personal impact

9. The migraine attack Symptom intensity Associated symptoms Prodrome Aura Headache Postdrome Time

10. Excitatory • Irritability • Elation • Hyperactivity • Yawning • Food cravings • Photophobia / phonophobia • Increased bowel / bladder activity Inhibitory • Mental / physical slowing • Poor concentration • Word finding difficulty • Weakness / fatigue • Constipation / abdominal bloating • Anorexia • Chill Prodrome • 60% of migraine sufferers experiencepremonitory phenomena

11. Aura • Affects 33% of migraine sufferers, but not in all attacks • Transient neurological symptoms resulting from cortical or brainstem dysfunction • May involve visual, sensory or motor systems • Can occur before or during headache phase • Slow evolution of symptoms • Lasts for 20-60 minutes • Can be confused with transient ischaemic attack Ferrari 1998 Spierings 2003 Russell & Olesen 1996

12. Aura v TIA AURA TIA Simultaneous occurrence <15 minute duration Negative symptoms Headache uncommon • Sequential Progression • 20-60 minute duration • Positive and negative symptoms • Headache occurs in 50% • Visual • Sensory

13. Headache phase • Throbbing or pounding quality • If left untreated, headache pain will progress to moderate / severe intensity • Duration 4-72 hours in adults • Exacerbated by movement* • One-sided temporo-orbital* (but can be any site) • Abated by sleep* • Resolves spontaneously *Usually

14. Postdrome • Estimated to affect 90% of migraine sufferers • Phase after pain relief • duration up to 24 hours • Sufferers may experience: hyperaesthesia, mood changes, muscular weakness, fatigue, difficulty in concentrating • Extends period of migraine-related disability Blau 1982

16. Cutaneous Allodynia • Perception of pain when non-noxious stimulus applied to normal skin • central sensitization of neurons in the trigemino-vascular system • wind-up • up to 70% migraineurs • treat early

17. What features make migraine more likely? • episodic severe headache that causes disability11, 23, 24 • nausea16, 23 • sensitivity to light during migraine headache16, 23 • sensitivity to light between migraine attacks 25 • aura16, 18 • sensitivity to noise16 • exacerbation by physical activity16 • positive family history of migraine16 • The features which give the greatest sensitivity and specificity are Disability, Nausea and Sensitivity to light23 • ID Migraine validation study (Level 3)

19. Trigeminal Autonomic Cephalalgias • Cluster headache • Paroxysmal Hemicrania • SUNCT

20. Cluster Headache • Men • smokers • severe pain (Eagle’s Claw) • high impact • autonomic features

21. Cluster IHS Criteria • Severe or very severe unilateral,supraorbital and or temporal pain lasting 15-180 min if untreated • Headache accompanied by one of the following • Ipsilateral conjunctival injection and or lacrimation • Ipsilateral nasal congestion and or rhinorrhoea

22. Cluster IHS • Forehead and facial sweating • Ipsilateral eyelid oedema • Ipsilateral forehead and facial sweating • Ipsilateral miosis and ptosis • A sense of restlessness or agitation • Attack frequency 1 every other day to 8 per day

23. Cluster • Episodic occurs in periods 7 days to 1 year separated by pain free periods lasting one month or more • Chronic attacks occur for > 1 year without remission or remission lasting less than a month

24. What features make TACs more likely? • The following features differentiate trigeminal autonomic cephalalgias from migraine: 16, 26 (Level 4) • Onset: rapid in TAC, gradual in migraine • Duration: TACs < 3 hours, migraine 4 - 72 hours • Frequency: multiple attacks may occur daily in TACs • Restlessness during an attack: 100% in cluster headache, 50% in paroxysmal hemicrania • Prominent ipsilateral autonomic features in TACs

25. Other Primary Headaches • Primary Stabbing Headache • Primary Cough Headache • Primary Exertional Headache • Primary Headache Associated with sexual Activity • Hypnic Headache • Hemicrania Continua

26. Any Questions?