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Headache

Headache. Dr Viviana Elliott Consultant Physician Acute Medicine. Aims. To provide a practical approach to the diagnosis and management of patients presenting with headache. Objectives. To be able to understand the causes of headache To be able to classify headaches in clinical practice

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Headache

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  1. Headache Dr Viviana Elliott Consultant Physician Acute Medicine

  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 • 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 40 -80 mg Propanolol before intercourse

  15. History taking • The most important investigation in the evaluation of headaches is HISTORY • First question to answer ourselves is whether it is a PRIMARY or SECONDARYheadache syndrome. • Any important red flags in history or examination to consider investigation for a secondary headache

  16. 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

  18. 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.

  19. 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

  20. 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.

  21. 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

  22. 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

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

  24. “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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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 !!!

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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 %

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

  39. 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

  40. Questions?

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