Headache

1. Headache Dr Viviana Elliott Consultant Physician Acute Medicine 2014

2. Aims • To provide a practical approach to the diagnosis and management of patients presenting with headache

3. Objectives • To be able to understand the causes of headache • To be able to classify headaches in clinical practice • To be able to organise a management plan for patients presenting with headache • To be able to identify headache that you can’t miss

4. Headache • 2.5 % of new emergency attendance • 15 % will have a serious cause

5. Which structures in the head ache?

6. Pain sensitive structures • Dura • Arteries • Venous sinuses • Para-nasal sinuses • Eyes • Tympanic membranes • Cervical spine

7. Classification of headaches • Primary headache • Hemicrania continua • Secondary headache

8. Primary headache • Migraine • Cluster headache • Tension Headache

9. Secondary Headaches • Head Trauma • CNS infection • Vascular disease • Intracranial pressure disorders • Other common causes of headache

10. Head trauma • Subdural • Extradural

11. CNS infection • Meningoenchephalities • Cerebral abscess

12. Vascular disease • Subarachnoid haemorrhage (SAH) • TIA/Stroke • Subdural- extradural- intracerebral haemorrhage • Arterial dissection • Cerebral Venous sinus thrombosis (CVST) • Giant cell arteritis (GCA) and vasculitis

13. Intracranial pressure disorders • Tumours • Idiopathic intracranial hypertension • Intracranial hypotension • Hydrocephalus • Intermittent ( eg Colloid cyst)

14. Other common headaches • Sinusitis • Glaucoma • Hyponatraemia • Toxins: alcohol excess and withdrawal • Drugs: calcium channel blockers and nitrates • Coital migraine/cephalgia 50% previous migraine Exclude SAH Propanolol 40 -80 mg or Indomethacin 25-100mg can be taken 30-60 minutes prior to sexual activity

15. History Onset Frequency Periodicity Duration Time to maximum intensity Time of the day Recurrence One type or more than one headaches Life style

17. Primary Headaches

22. Note on treatment of migraine • All treatments should take into account the person’s preference, co morbidities, risk of adverse events and the impact of the headache on their quality of life. • People who are on another form of prophylaxis eg amitriptyline and who’s migraine is well controlled should continue with the same treatment • Continue prophylaxis for 6 months • Riboflavin 400 mg once a day may reduce the frequency and intensity of the migraines for some people.

23. Atypical Aura in Migraine that needs imaging • Motor weakness or • Double vision or • Visual symptoms affecting only one eye • Poor balance • Decrease level of consciousness

24. Menstrual related migraine • Migraine that occurs 2 days before and 2 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles • Diagnose menstrual related migraine using a headache diary for at least 2 menstrual cylces • Treatment if no response with standard acute treatment consider frovatriptan (2.5 mg bd) or zolmitriptan (2.5 mg bd or tds) on the days that the migraine is expected.

25. Medication overuse headache Headache developed or worsened while taking the following drugs for 3 months or more: • triptans, opioids, ergots or combination analgesic medication on 10 days per month or more. • Paracetamol, aspirin or an NSAID either alone or in combination, on 15 days per month or more

26. Treatment • Advice to stop ( abruptly) overused medication for a month. • Advice that headache will be worse before it improves ( withdrawal ). Close follow up and support. • Consider prophylaxis for primary headache • No need for admission • Referral to specialist only if use of strong opioids , relevant co-morbidities or unsuccessful attempts

27. Hemicrania continua • Unilateral headache for > 3 months Frontal temporal region periorbitally Few bilateral cases • Daily and continuous pain • Severity is moderate 74% fluctuating in severity 40% disabling exacerbation Exacerbations result in sever pain lasting 30’ to 10 hs (2-5 days) During exacerbation is indistinguishable from migraine

28. Hemicrania continua • Pain is sharp like “jab and jolts” 18% ocular sensation (like sand in the eye) accompany or precede the headache • Pain is throbbing (one third of cases); may appear as pain intensity increases • During exacerbation accompanied by at least one of this autonomic phenomena/signs: Conjunctival injection/lacrimation Nasal congestion/ rhinorrhoea Miosis and ptosis

29. Hemicrania continua Complete response to indomethacin 25 mg tds after 3 days increase to 50 mg tds may require up to 150 mg. If gastric intolerance Topiramate

30. Acute SAH Important headaches that you can’t miss(Secondary headache) Temporal arteritis • GlioMe Glioma Meningitis Cerebral Venous thrombosis

31. “SNOOP – T” Red flags for secondary headaches • Systemic symptoms ( fever weight loss) or Secondary risk factors: systemic disease, cancer or HIV • Neurological symptoms +/- abnormal signs ( confusion impair alertness or consciousness and focal sign) • Onset: sudden, abrupt or split of a second or worsening and progressive • Older new onset and progressive headache specially in middle age, > 50 years ( giant cell arthritis) • Previous headache history first headache or different ( significant change in attack frequency, severity or clinical features • Triggered Headache by Valsalva, exertion or sexual intercourse

32. Bacterial Meningitis • High level of suspicious if fever and altered consciousness!!! • Acute bacterial meningitis is an important fatal medical emergency- early recognition saves lives!! • Prompt initiation of antibiotics • Confirm diagnosis & pathogen with CSF analysis via lumbar puncture • Still obtain CSF even if antibiotics commenced eg Polymerase Chain Reaction (PCR) for bacteria DNA

33. Subarachnoid haemorrhage • Commonest potentially life threatening acute severe headache 1-3% headaches presenting to A&E • 1/3 present with acute onset of severe headache as only symptom! • Headache characteristics - Acute or Abrupt Thunderclap” Instantaneous 50% Seconds< minute 25% 1-5 minutes 20% Over 5 minutes zero • “Worse ever” : more likelihood • Transient lost of consciousness or epileptic seizure

34. CT Brain ASAP !( sensitivity decreases with time) • First 12 hs 96 – 100% • Within 24 hs 92 – 95 % • Within 48 hs 86 % • At 5 days 58 % • At 7 days 50 % • After 2 weeks 30 % • After 3 weeks almost nil

35. Chronology of CSF abnormality in CSF • 12 hs should elapse before CSF analysis for xanthochromia –immmediate centrifugation • Red cell lysis in the CSF to billirubin and oxyhaemoglobin • Xanthochromia reliably present >12 hs and up to 2 weeks of SAH

36. Management of SAH • Call a friend : Neurosurgery • Analgesia & anti-emetics • Reduce secondary ischemia Nimodipine 60 g 4 hrly • Supportive care to reduce brain insult Adequate hydration > 3 lts of saline daily Avoid hypotension Avoid hypoxia • Early Neurovascular MDT • Complications: Hydrochephalus

37. Giant Cell arteritis • Affects large/medium size arteries • Microscopically infiltration of lymphocytes, macrophages, histiocytes and multinucleates giant cells • Vessel are tender, red, firm and pulsless with scalp sensitivity • Risk of blindness if not treated

38. Presentation • Rare before 50 • Female > male • Insidious onset • Often associated with jaw claudication on chewing • Headache localised to the superficial occipital or temporal arteries, throbbing and worse at night • 75% raised CRP and ESR • Diagnostic biopsy with in 2 weeks • Prednisolone 60 mg

39. Cerebral Venous Sinus ThrombosisHeadache presentation • Acute/ subacute progressive “headache plus” syndrome Papilloedema “ idiopathic intracranial hypertension” mimic Symptoms of raised ICP VI nerve palsy Focal signs Seizures Enchephalopathy • Acute Thunderclap – SAH like presentation CT –ve, CSF negative -Consider specially if raised CSF OP • New daily persistent headache • Isolated headache !!!

40. CVST: appropriate investigations • D-Dimer level? Abnormal in 96% with enchephalopathy Normal in ¼ with isolated headache • Brain MRI/MRV (T2) Sinus occlusion Venous haemorrhage Venous infarction • CT venogram

41. CVST: management- anticoagulation • Low molecular weight heparin or IV Heparin • 3-6 months Warfarin • Thrombolisis? • Treatment of comorbidities, seizures and increased ICP Consider Anticardiolipin antibody syndrome, Thrombotic & Homocystein screen Cancer CNS and ENT infection Systemic inflammatory disease/Behcets

42. Carotid dissection A hemorrhage into the wall of the carotid artery, separating the intima from the media and leading to aneurysm formation. Suspect in • Blunt trauma? Post RTA • Rotational forces? Manipulation • Spontaneous

44. Acute Cervical arterial dissection Internal carotid artery dissection (ICAD) • Unilateral headache/face pain + neck +/- Contra lateral stroke or TIA Vertebral artery dissection (VAD) • Occipital-nuchal headache +/- posterior circulation TIAs

45. CAD Investigations • MRI Brain and neck & MRA (Carotid & vertebral) Crescent shaped intramural haematoma & vessel occlusion Identifies ischemic brain tissue > clearly • CT brain & CTA of cervical vessels Tapering lumen, vessel occlusion • Rarely Catheter angiogram Intimal flap +/- double lumen path gnomonic seen in <10 %

46. Management of carotid artery dissection • “Ring a friend” neurology • Aspirin vs anticoagulation 3-6 month therapy

47. Conclusions • Remember that history is the most important clue • Describe a classification useful in clinical practice Primary headache (migraine – cluster - tension) Head Trauma CNS infection Vascular disease Intracranial pressure disorders • Remember “SNOOP – T” • Don’t miss: Brain tumours, Giant arteritis, carotid dissection, meningitis and SAH ! Snoop-T

48. Questions?