RED FLAGS IN HEADACHE; A HEADACHE FOR THE MAU DOCTOR

1. RED FLAGS IN HEADACHE; A HEADACHE FOR THE MAU DOCTOR FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST

2. Objectives • Recognising red flags in Headache • Clinical Features of Serious Headache Disorders • Investigation plan and further referral

4. 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

5. DILEMMA IN MAU/A&E

6. 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?

7. SERIOUS HEADACHES Subarachnoid Haemorrhage Brain Tumours or Space Occupying Lesion (SOL) Infections like Meningitis, Encephalitis Temporal arteritis

8. 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

9. 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

10. 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

11. 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

12. 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

14. 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

15. 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

16. 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

17. SYMPTOMS of Raised ICP • Headaches worse on straining and Early Morning • Nausea and Vomiting • Drowsiness • Visual Symptoms • Seizures

18. SIGNS of Raised ICP • Impairment in Conscious Level (GCS<15) • Papilloedema • Hypertension • Bradycardia • False localising signs such as VI N palsy • Focal Neurological Signs

20. CT Meningioma

21. G.B.M

22. Cerebral Metastasis

23. Cerebral Venous Thrombosis • Female, Smoker, OCP, Postpartum • Dehydration, Hyperviscosity • Drowsy, Seizures, Focal Signs

24. Cerebral Venous Thrombosis • Clinical Suspicion • CT Venogram/MRA • Anticoagulation

26. Benign Intracranial Hypertension • Female, Overweight, Smoker, OCP • Visual Symptoms • Papilloedema

27. Benign Intracranial Hypertension • Clinical Suspicion • CT/MRI MRA • Lumbar Puncture • Acetazolamide/Topiramate/Diuretic

28. 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

29. 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

30. 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.

32. FEBRILE HEADACHES; DAYS • Meningitis – Viral, Bacterial • Encephalitis

33. ENCEPHALITIS: Symptoms/Signs • Headaches and altered conscious level • Seizures • Focal Signs

34. ENCEPHALITIS: Diagnosis • CT/MRI (Diffuse or Focal Oedema) • EEG (Slow waves over affected area) • CSF (Lymphocytes) PCR positive for HSV-1,VZV • Acyclovir

35. 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

36. 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

37. JOIN • Special rates for Trainees/Nurses/Therapists • Electronic or Paper copies of Cephalalgia • Invitation to BASH meetings • BASH NEWSLETTER (www.bash.org.uk)

38. 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