Managing Headache (without breaking the bank)

1. Greater Manchester Neuroscience Centre Managing Headache (without breaking the bank) Implementation of useful referral guidelines Dr Adam Zermansky Consultant Neurologist

2. Managing Headache (without breaking the bank) Latest Greek Bailout Cost of Headache €130 billion €173 billion1 1 Eur J Neurol December 2011

3. Scale of the problem • At least 10% population suffer from headache • 1-2% suffer chronic migraine (>15 days/month) • 4.4% per year consult GP for headache1 • 20% of sickness absence from work2 1 Latinovic R et al. JNNP 2006;77:385-387 2 Rasmussen BK. Cephalalgia 2001; 21:774-7

4. Salford GP Referrals to SRFT 2005 - 2009 4500 Cardiology Haematology 4000 Immunology 3500 Dematology ENT 3000 Gastro Triage rate per 1000 Patients Gen Medicine 2500 Number of referrals per year 35.0 Gen Surgery Neurology Referral per 1000 patients 2008-9 2000 Gynaecology 30.0 Neurology 1500 25.0 Neurosurgery Respiratory 1000 Triage rate per 1000 Patients 20.0 Rheumatology 15.0 500 Orthopaedics Neurosurgery Urology 10.0 0 2005 2006 2007 2008 2009 Year 5.0 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 Practices in descending order of referrals Audit results courtesy of Dr Jon Sussman

5. Many patients referred before trying treatment 100 90 80 Treated 70 60 50 Untreated 40 30 20 10 0 Audit results courtesy of Dr Jon Sussman Low Med High V. High Extr. High

6. Guidelines needed? • Increasing referrals • Many patients untreated • Educational aid, easier than turgid BASH/SIGN • Pilot in Salford: saved PCT £100,000 in 1 year

7. Headache Management Pathway Adult with Headache Emergency symptoms? Refer to appropriate on-call hospital team Yes • Thunderclap onset • Accelerated/Malignant hypertension • Acute onset with papilloedema • Acute onset with focal neurological signs • Head trauma with raised ICP headache(see red flags) • Photophobia + nuchal rigidity + fever +/-rash • Reduced consciousness • Acute red eye: ?acute angle closure glaucoma • New onset headache in: • 3rd trimester pregnancy/early postpartum • Significant head injury • (esp. elderly/ alcoholics / on anticoagulants)

8. Headache Management Pathway Adult with Headache Emergency symptoms? Refer to appropriate on-call hospital team Yes No Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy) Giant cell arteritis? Yes • Symptoms and signs:- • jaw/tongue claudication, amaurosis, scalp tenderness • temporal artery: prominent, tender, diminished pulse • other cranial nerve palsies, limb claudication • PMR • Many headaches respond to high dose steroids, so do not use response as the sole diagnostic factor • ESR can be normal in 10% (check CRP as well) www.rheumatology.org.uk/includes/documents/cm_docs/2010/m/2_management_of_giant_cell_arteritis.pdf

9. Headache Management Pathway Adult with Headache Emergency symptoms? Refer to appropriate on-call hospital team Yes No Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy) Giant cell arteritis? Yes No Red flags? Refer Yes • Raised intracranial pressure:- • Wakes from sleep (but not migraine or cluster) • Precipitated by Valsalva manoeuvres (cough, straining at stool) • Papilloedema • Other symptoms of raised ICP headache include:- • Present upon waking and easing once up (MOH can cause this phenomenon) • Whooshing pulse-synchronous tinnitus • Episodes of transient visual loss when changing posture (e.g. upon standing) • Vomiting (in context as migraine causes this!) • New onset seizures • Persistent new or progressive neurological deficit • Increasing in severity and frequency despite appropriate treatment • Undifferentiated headache of recent origin and present for >8 weeks • Triggered by exertion • New onset headache (< 6 months) in:- • >50 years old (consider giant cell arteritis); interrogate patient about previous ‘normal headaches’ as it might not be ‘new’ • Immunosuppressed / HIV / relevant history of cancer

10. Headache Management Pathway Adult with Headache Emergency symptoms? Refer to appropriate on-call hospital team Yes No Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy) Giant cell arteritis? Yes No Red flags? Refer Yes No Migraine or tensionheadache? Primary or Secondary?

11. Categorisation: Primary

12. Categorisation: Secondary

14. The 1 in 10,000 problem… Migraine

15. Brain Tumour Headache • What symptoms did they have before? • Headache: What % have BT? • BT: What symptoms do they have now?

16. Brain Tumours: symptoms BJGP 2007 (any) Tumour 6 months Control Population risk 0.01%

17. Headache: secondary causes What happens to new-onset headache presented to primary care? A case-cohort study using electronic primary care records D Kernick, S Stapley, PJ Goadsby & W Hamilton Cephalalgia 2008 Undifferentiated headache Brain tumour 0.15% 1 in 1250 <50 1 in 360 >50 Primary headache Malignant brain tumour 0.045% i.e. 1 in 2222 Background BT incidence 0.013 %

18. Brain Tumour Headache: What’s it like? • Headache common 50% of patients • Bland, featureless • Episodic • Responds to simple analgesic • New or change pattern • Raised ICP type headache is rare (5.1%)

19. Head scan / referral? • Raised ICP headache • Early morning / waking • Valsalva or exertion triggered • Bland unclassifiable headache in over 50s (take proper history) • New onset / change in headache • >50y • HIV • Cancer • thrombotic tendency • Headache+ • GCA, atypical aura, seizures, fever and neck stiffness, thunderclap, abnormal neurology • ?? Therapeutic scan

20. Therapeutic scan and VOMIT • GP reassurance • < 1y patient reassurance • Incidentaloma: 1 in 37 • Cysts • aneurysms • Vascular anomalies • Inflammatory • Developmental (AC) • WML • Neoplasms

21. Messages • Brain tumours rare (1/10k) • Primary headache: brain tumour still rare • Diagnose the headache type • Think about red flags, even if primary headache • Caution: VOMIT from ‘therapeutic scans’

22. Migraine • Unilateral onset • Throbbing • 4 – 72 hours • Sensory Sensitivity • Light • Sound • Smells • Movement migraine behaviour

23. Common misdiagnosis of migraine • Cervicogenic Headache (30% migraine→neck pain) • Chronic Tension Type Headache • Eye Strain • Dental • TMJ dysfunction • Sinus headache • Hypertensive Headaches

24. IHC II aura • focal neurological symptoms • develop over 5-20 minutes • last for < 60 minutes

25. Aura • Fortification spectra = teichopsia • Photopsia • Scotoma • Shimmering • Paraesthesia • Hemiparesis Vauban 17th century

26. Cluster Headache Pain Agitation Autonomic Lasts 30 – 120 minutes ?? Glaucoma www.ouchuk.org

27. Migraine Treatment: acute • Aspirin 900mg + metoclopramide (and/or paracetamol) • NSAID • Triptans: 5-HT 1b/d agonists • Almotriptan • Eletriptan • Frovatriptan • Naratriptan • Rizatriptan • Sumatriptan • Antipsychotics: chlorpramazineetc • Steroids? Generic and fastest acting

28. Migraine Treatment: Prophylaxis • Propranolol • Amitriptyline • (pizotifen….no evidence…..gain weight and sleepy) • Topiramate • Wtloss, paraesthesia common • Memory problems, 1% renal calculi • Gabapentin • unusual stuff: Botox, methysergide, lisinopril... • Alternative stuff: • Feverfew+riboflavin, butterburr, Mg, acupuncture BMJ 2011;342:d583 Pharmacological Prevention of Migraine

29. No Headache Management Pathway Adult with Headache Emergency symptoms? Refer to appropriate on-call hospital team Yes No Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy) Giant cell arteritis? Yes No Red flags? Refer Yes No further treatment Refer No Try acute treatments Migraine or tensionheadache? No No Secondary causes? e.g. sinusitis, TMJ pain Hb, Ca2+, TFT,ESR, CRP R/V lifestyle & medication Treat as necessary Yes • Suspect:- • Medication overuse headache (MOH)? • Drug induced? Stop offending medication (for 2 months if MOH) No Still troublesome? Cluster headache? Still troublesome? Yes Yes No Yes Yes Prescribe acute treatment (< 10 times/month) Can you diagnose migraine or tensionheadache? Yes • If relevant, stop combined oral contraceptive • Ensure not overusing analgesics or triptans • Modify lifestyle (adequate sleep, hydration, reduce caffeine intake, trigger avoidance) • If prophylaxis necessary, try the following for 3 months at the target dose before judging efficacy:- • Migraine prophylaxis • Propranolol SR 80mg o.d. increase gradually to 240mg o.d. or maximum tolerated below that • If ineffective or contraind: Amitriptyline 10mg o.n. increasing by 10mg/week to ≤75mg • Don’t bother with pizotifen (weight gain, sedation, little benefit) • If above ineffective/not tolerated, try Topiramate 25mg o.d. increasing by 25mg every 2-weeks aiming for a target of 50mg b.d. NOTE: teratogenic and potential interaction with combined oral contraceptive • Tension Type Headache prophylaxis • Amitriptyline 10mg o.n. increasing by 10mg a week up to 75mg or maximum tolerated below that Still troublesome? Yes No Continue treatment for 9-12 months; then consider stopping

30. What the patient thinks….. x x

31. The reality….. Scan Primary headache: Play 3 games to find 1 tumour

32. Don’t forget: GCA