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RED FLAGS IN HEADACHE; A HEADACHE FOR THE MAU DOCTOR. FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST. Objectives. Recognising red flags in Headache Clinical Features of Serious Headache Disorders Investigation plan and further referral. HEADACHES.
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RED FLAGS IN HEADACHE; A HEADACHE FOR THE MAU DOCTOR FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST
Objectives • Recognising red flags in Headache • Clinical Features of Serious Headache Disorders • Investigation plan and further referral
HEADACHES • One of the commonest symptom • Account for 30% GP and 50% Neurology Referrals • 95% of the population at some stage experience headaches • 15-19% of Acute Medical Admissions(1), 55% of Neurology in A & E(2) 1. Weatherall M., J RCP Edinb 2006; 36: 196-200 2. Craig J., Patterson V., Roche L., JamisonJ., Accident and Emergency Neurology: time for a reappraisal? Health Trends, 1997, 29, 89-91
DILEMMA IN MAU/AE • AM I DEALING WITH A SERIOUS HEADACHE ? • DO I URGENTLY INVESTIGATE OR ASK FOR HELP NOW OR AS AN OP ? • WHO DO I ASK FOR HELP; NEUROLOGIST OR NEUROSURGEON? • AM I OK TO SEND THIS PATIENT HOME?
SERIOUS HEADACHES Subarachnoid Haemorrhage Brain Tumours or Space Occupying Lesion (SOL) Infections like Meningitis, Encephalitis Temporal arteritis
RECOGNISE SERIOUS HEADACHESRED FLAG HEADACHES Hyperacute onset no previous history Gradually progressive no previous history Presence of any neurological signs Headaches above the age of 60 Change in characteristics or pattern
NON URGENT HEADACHES • Round the Clock for > 3 months • No Neurological Signs • Acute Exacerbations of Known Migraines • Episodic Headaches > 6 months with clear headache free intervals
Thunderclap Headache (TCH) • Peaks within a minute • Primary and Secondary (Clinically cannot differentiate)1 • Primary TCH – Diagnosis of exclusion • SAH – CT/LP earlier or CTA later • Arterial Dissection – Focal Neurological signs • Pituitary Apoplexy – CT/MRI abnormal • Venous Sinus Thrombosis – Raised CSF, CTV • Spontaneous Intracranial Hypotension –Typical history 1. Linn et al JNNP 1998:65; 791-3
SAH • 11 per 100,000 • 85% Saccular Aneurysm, 10% perimensephalic 5% AVM • Peaks within a minute and last at least an hour • Worst Ever • May be associated with LOC • NV Photo/phonophobia • Neck Rigidity, Kernig’s sign
SAH • CT scan Sensitivity1 • 97% within 12 hours • 85% after 24 hours • 76% after 48 hours • 58% after 5 days • LP Xanthocromia • 100% 12 hrs – 2 weeks • 70% week 3 • 40% week 4 1. Van der Wee et al JNNP 1995
SAH – MISDIAGNOSIS • Reasons1 • The diagnosis was not considered • Failure to understand limitations of CT • Failure to properly perform / analyse CSF • Wrong investigation – MRI/MRA • 1 in 20 SAH patients are missed in A & E2 • NEGM 2000, 342; 29-36 • Stroke 2007, 38; 1216
SAH - MISDIAGNOSIS • Instantaneous headaches only in 50% • 1 in 6 SAH may present with a fit • 1-2% present with acute confusion • LP is traumatic • Focusing on hypertension and arrhythmia
RECENT AND PROGRESSIVE HEADACHESweeks to < 3/12 • EXCLUDE • SOL • Cerebral Venous Sinus Thrombosis • Idiopathic Intracranial Hypertension • > 55 Consider Temporal Arteritis • NEW DAILY PERSISTENT HEADACHES • Diagnosis of exclusion • Daily unremitting from onset • Migrainous or TTH
SYMPTOMS of Raised ICP • Headaches worse on straining and Early Morning • Nausea and Vomiting • Drowsiness • Visual Symptoms • Seizures
SIGNS of Raised ICP • Impairment in Conscious Level (GCS<15) • Papilloedema • Hypertension • Bradycardia • False localising signs such as VI N palsy • Focal Neurological Signs
CT Meningioma
Cerebral Venous Thrombosis • Female, Smoker, OCP, Postpartum • Dehydration, Hyperviscosity • Drowsy, Seizures, Focal Signs
Cerebral Venous Thrombosis • Clinical Suspicion • CT Venogram/MRA • Anticoagulation
Benign Intracranial Hypertension • Female, Overweight, Smoker, OCP • Visual Symptoms • Papilloedema
Benign Intracranial Hypertension • Clinical Suspicion • CT/MRI MRA • Lumbar Puncture • Acetazolamide/Topiramate/Diuretic
TEMPORAL ARTERITIS; Features • Uncommon below the age of 55 • Women twice as much as Men • Common in British / Scandinavian • Fairly Uncommon in Asian/Africans Bengtsson B-A, Malmvall BE. Giant Cell Arteritis, Acta Med Scand, 1982;658:1-102
TEMPORAL ARTERITIS; Symptoms • Recent onset on uni or bilateral temporal Headaches • Cutaneous Allodynia • Jaw Claudication • Systemic Symptoms • Pain and aching in Shoulder/Pelvic girdle muscles
TEMPORAL ARTERITIS; Diagnosis • Clinical Suspicion • ESR/PV and CRP Normal < 1% • Temporal Artery Biopsy – Controversial • Steroids Hayreh SS, Podhajsky PA, Raman RI. Giant Cell Arteritis; Validity and Reliability of various diagnostic criteria. Am j Ophthalmol 1997;123:285-296.
FEBRILE HEADACHES; DAYS • Meningitis – Viral, Bacterial • Encephalitis
ENCEPHALITIS: Symptoms/Signs • Headaches and altered conscious level • Seizures • Focal Signs
ENCEPHALITIS: Diagnosis • CT/MRI (Diffuse or Focal Oedema) • EEG (Slow waves over affected area) • CSF (Lymphocytes) PCR positive for HSV-1,VZV • Acyclovir
Headache that Needs Urgent ImagingBASH guidelines • Clinical signs present • Pronounced signs of raised intracranial pressure • Change in cognitive functional personality • Relevant systemic disease • Worst headache ever particularly if crescendo is reached in minutes or rapidly deteriorating
SUMMARY • Serious Causes are Uncommon • SAH, Meningitis, Encephalitis SOL and TA are the main serious headaches • Refer to Neurosurgeon (SAH) or Neurologists when in doubt
JOIN • Special rates for Trainees/Nurses/Therapists • Electronic or Paper copies of Cephalalgia • Invitation to BASH meetings • BASH NEWSLETTER (www.bash.org.uk)
BASH MEETINGS IN 2011/12 • GLASGOW JUNE 15-16 2011 • PLYMOUTH OCTOBER 2011 • LONDON APRIL 2012 • KEELE SEPTEMBER 2012 • Contact Debbie.Buttle@hey.nhs.uk