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Headache

Headaches - . Very common presenting complaint in General practicePrimary /secondaryHeartsink! <1% patients presenting with headache have a brain tumour

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Headache

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    1. Headache Lorne Forster 08/01/08

    2. Headaches - Very common presenting complaint in General practice Primary /secondary Heartsink ! <1% patients presenting with headache have a brain tumour……

    3. Guidelines - NICE – none SIGN – due autumn 2008 British Association for the Study of Headache – 52 page document – www.bash.org.uk MayoClinic.com www.clevelandclinic.org/health/

    5. Diagnosis - Detailed history As for any pain May be more than one type of headache Use of symptom diary Examination BP, fundi, head &neck, +/- neuro. exam 0.9% patients without neuro. signs had pathology Isolated headache >10 weeks only exceptionally tumour ?Investigations PV if possible temporal arteritis (Open access CT scan)

    6. Warning Features - New or unexpected headache Thunderclap headache Atypical aura New onset aura with COCP New headache in >50y or <10y Progressive headache Associated postural change Known cancer or HIV

    7. Migraine - Recurrent and episodic Moderate to severe intensity 4-72 hours Unilateral, pulsating GI upset, photophobia, phonophobia Prefer to rest in darkened room +/- aura Classically visual, 5-60 minutes prior to headache

    8. Migraine - management No cure Avoidance of predisposing or triggering factors Regular meals Sleep hygiene Exercise

    9. Migraine – acute attack treatment ladder 1. Oral analgesia +/- anti-emetic Aspirin 600-900mg qds ideally soluble Ibuprofen 400-600mg qds ideally soluble Prochlorperazine / domperidone / metoclopramide Eg OTC Migramax, Paramax Not if – aspirin / NSAID intolerance 2. Rectal analgesia +/- anti-emetic Diclofenac supp 100mg (200mg/24h) Domperidone supp 30-60mg (120mg/24h) Not if – NSAID intolerance, diarrhoea, patient objection Take early and avoid codeine

    10. Migraine – acute attack treatment ladder 3. Specific anti-migraine drugs Triptans 20-50% relapse, repeat >2h if worked Ergotamine if relapse a problem Not if – uncontrolled BP, CHD / CVD risk, children <12y Take only once headache started 4. Combinations Emergency Diclofenac 75mg i.m. Chlorpromazine / metoclopramide i.m. Avoid opiates and opioids

    11. Migraine - prophylaxis = 4 attacks per month In addition to acute therapy Try drug for 6-8 weeks If effective, continue for 4-6 months then withdraw over 2-3 weeks 1. B blockers, amitriptyline (unlicensed) 2. Topiramate, sodium valproate (unlicensed) 3. Gabapentin (unlicensed) Pizotifen - ?lack of evidence, but use in children

    12. Tension-type Headache - Mild to moderate intensity Episodic / chronic (=15 days / month) Bilateral / generalised Pressure / tightness, ‘band-like’ +/- nausea, photophobia, phonophobia Stress-related Musculoskeletal element Can co-exist with migraine

    13. Tension-type Headache - treatment Reassurance Relaxation Physio. for musculoskeletal element Simple analgesia (avoid codeine) For chronic TTH Naproxen 250-500mg bd 3 weeks Amitriptyline 10-75mg nocte 4-6 months

    14. Cluster Headache - Intense Daily, often 1-2 hour after falling asleep Focused around one eye with associated autonomic sympoms Typically : male, >20y, smoker Agitated, pacing Specialist referral Sumatriptan 6mg sc, 100% O2 10-15L/min

    15. Medication-overuse Headache - 1:50 adults, ?:? 5:1 Often present on wakening Increases with exertion History of episodic headache eg migraine Increasing frequency of analgesic use

    16. MOH – treatment - Abrupt withdrawal 1-2 weeks sick leave Symptoms worsen first week then abate Hydration, symptom diary Drugs Naproxen 250mg tds 2/52, 250mg bd 2/52, 250mg od 2/52 Amitriptyline 10-75mg long-term

    17. Scary Heads - Intracranial tumours Meningitis / encephalitis SAH Temporal arteritis Acute closed angle glaucoma Idiopathic intracranial hypertension CO poisoning

    18. Temporal Arteritis - New headache >50y of age Persistent, worse at night, severe Systemically unwell Marked scalp tenderness Minority localised to temples Jaw claudication Raised ESR /PV

    19. Temporal Arteritis – treatment - Prednisolone 1mg/kg/day (max. 60mg od) Refer rheumatology or ophthalmology for temporal artery biopsy

    20. The End!!! Made by Dr. Lorne Forster With the help of her daughter, TAZ!

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