HEADACHES; When to seek advice?

1. HEADACHES; When to seek advice? DR FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST

2. LEARNING OUTCOME Headaches requiring urgent advice from GP Headaches requiring expertise from a Neurologist/Headache specialist Uncommon but potentially serious headaches Common Headache Disorders in the population

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

6. HEADACHES REQUIRING URGENT GP CONSULTATION Sudden onset of worst ever headache Headaches with fever/rash drowsiness Rapid progression of new onset headache New headache starting after age 50 Change in characteristics or pattern of longstanding headache

7. HEADACHES REQUIRING SPECIALISTS’ INPUT • Difficulty in establishing a diagnosis • Migraine/Tension headache refractory to treatment • Headaches requiring frequent analgesia • Short lasting headaches/symptoms suggesting Cluster Headaches

8. PRIMARY VS SECONDARY HEADACHES • Primary Headaches have no underlying cause and are mostly harmless and potentially treatable e.g. Migraine, Tension Headaches • Secondary Headaches have an underlying cause and are still potentially treatable

9. SECONDARY HEADACHES • NON SERIOUS (Common ) • Referred Headaches • Medication Overuse • Minor Head Injury

10. Causes of Referred Headaches • Eyes – Errors of Refraction • ENT – Sinuses • Teeth – Peridontal Disease • Jaw – Temporomandibular dysfunction • Neck – Degenerative Spinal Disease

11. SECONDARY HEADACHES • Serious (< 1%) • Brain Tumours • Brain Haemorrhage • Meningitis/Encephalitis • Temporal Arteritis

12. PRIMARY HEADACHES • Virtually All of them are Benign or Harmless • Tension Headache is the commonest • Migraine is the second most common • Cluster Headaches and Neuralgias are uncommon but treatable

13. PRIMARY HEADACHES • Tension Headaches (60-75%) • Migraines (15-25%) • Others like Cluster Headaches, Neuralgia(<1%)

14. SHORT VS LONG DURATION HEADACHES • < 4 HOURS Ice Pick Headaches Cluster Headaches Neuralgias • > 4 HOURS MIGRAINES TENSION HEADACHES MEDICATION OVERUSE HA

15. How to Recognise Tension Headaches ? • Pressure, Like a band, Head in a vice • Usually all over the head • Sickness and Sensitivity to light and sound is fairly uncommon • Stressful event/ Worrying about tumour

17. How to recognise Migraine ? • Pulsating/Throbbing • Unilateral/Bilateral frontal/temporal • Sickness and Sensitivity to light/sound/smell • Exacerbation with Physical activity • Lasting more than 4 hours unless a good analgesic response.

19. TYPES OF MIGRAINE • Common Migraine (Migraine without Aura) • Classical Migraine (Migraine with Aura) • Migrainous Aura without Headaches

20. How to Recognise a Migraine Aura ? • Symptoms similar to a Transient Ischaemic Attack (MINI STROKE) • Young age • Family History • Gradual progression of symptoms • Visual aura is commonest

21. Visual Aura

22. Scotoma

23. Visual Blurring

24. How to recognise Cluster Headaches ? • More common in Men (M:F = 6:1) • More common in Smokers (90%) • Excruciating Headaches • 2-8 times per day each lasting 30-120 minutes • Strictly unilateral/frontal/around eyeball • Runny Blood Shot and droopy eye • Early morning attacks

25. ClusterHeadaches

28. How to Recognise Medication Overuse Headaches ? • Usually cause Round the Clock Daily headaches (Chronic Daily Headaches) • Consumption of Painkillers for 15 or more days per month for more than 3 months • More common with opiate analgesics, ergotamine and triptans

29. Chronic Migraine • Headache for 15 days or more • 8 days of migraine headaches • With or without medication overuse • Triggers are more common • Most disabling of all headache disorder excluding cluster headache • Usually without aura

30. How to recognise Neuralgias ? • Attacks are very short i.e., few seconds • Trigeminal Neuralgia is the commonest • Attacks precipitated by chewing, brushing, shaving and speaking • Mainly over cheeks / Jaw not around eyes

31. Standard abortive therapy Migraine; How to manage?

32. Migraine; How to manage? • Identify any obvious triggers • Infrequent attacks • Acute treatment only • Frequent attacks • Acute and Preventative treatments

34. ROLE OF SPECIALIST CLINICS • Establish or Re-confirm the Diagnosis • Investigations if necessary • Appraise the available treatments for an individual • Identify the best possible acute and/or preventative treatment/alternatives • Provide information on treatment outcomes • Advise on new treatments • Provide support through Specialist Nurse

35. I WANNA TRY BOTOX NEXT

36. BOTOX • Licensed for Chronic Migraine • Not available on the NHS yet • Multiple small injections in head muscles • Effect last for 4-6 months • Currently clinicians being trained to do it • Case is being made for NHS Rx

37. THANK YOU ANY QUESTIONS