02/05/20151 HEADACHES; When to seek advice? DR FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST.

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HEADACHES; When to seek HEADACHES; When to seek advice?advice?

DR FAYYAZ AHMEDDR FAYYAZ AHMEDCONSULTANT NEUROLOGISTCONSULTANT NEUROLOGIST

HULL & EAST YORKSHIRE HOSPITALS HULL & EAST YORKSHIRE HOSPITALS NHS TRUSTNHS TRUST

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

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HEADACHESHEADACHES

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: 196-2002. Craig J., Patterson V., Roche L., JamisonJ., Accident and Emergency Neurology: time for a reappraisal?

Health Trends, 1997, 29, 89-91

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HEADACHES REQUIRING URGENT HEADACHES REQUIRING URGENT GP CONSULTATIONGP CONSULTATION

Sudden onset of worst ever headacheSudden onset of worst ever headache

Headaches with fever/rash drowsinessHeadaches with fever/rash drowsiness

Rapid progression of new onset headacheRapid progression of new onset headache

New headache starting after age 50New headache starting after age 50

Change in characteristics or pattern of Change in characteristics or pattern of longstanding headachelongstanding headache

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

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PRIMARY VS SECONDARY PRIMARY VS SECONDARY HEADACHESHEADACHES

Primary Headaches have no underlying Primary Headaches have no underlying cause and are mostly harmless and cause and are mostly harmless and potentially treatable e.g. Migraine, Tension potentially treatable e.g. Migraine, Tension HeadachesHeadaches

Secondary Headaches have an underlying Secondary Headaches have an underlying cause and are still potentially treatablecause and are still potentially treatable

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SECONDARY HEADACHESSECONDARY HEADACHES

NON SERIOUS (Common )NON SERIOUS (Common )1.1. Referred HeadachesReferred Headaches

2.2. Medication OveruseMedication Overuse

3.3. Minor Head Injury Minor Head Injury

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Causes of Referred HeadachesCauses of Referred Headaches

Eyes – Errors of RefractionEyes – Errors of Refraction

ENT – SinusesENT – Sinuses

Teeth – Peridontal DiseaseTeeth – Peridontal Disease

Jaw – Temporomandibular dysfunctionJaw – Temporomandibular dysfunction

Neck – Degenerative Spinal DiseaseNeck – Degenerative Spinal Disease

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SECONDARY HEADACHESSECONDARY HEADACHES

Serious (< 1%)Serious (< 1%)

1.1. Brain TumoursBrain Tumours

2.2. Brain HaemorrhageBrain Haemorrhage

3.3. Meningitis/EncephalitisMeningitis/Encephalitis

4.4. Temporal ArteritisTemporal Arteritis

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PRIMARY HEADACHESPRIMARY HEADACHES

Virtually All of them are Benign or Virtually All of them are Benign or HarmlessHarmless

Tension Headache is the commonestTension Headache is the commonest Migraine is the second most commonMigraine is the second most common Cluster Headaches and Neuralgias are Cluster Headaches and Neuralgias are

uncommon but treatableuncommon but treatable

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PRIMARY HEADACHESPRIMARY HEADACHES

Tension HeadachesTension Headaches (60-75%) (60-75%)

MigrainesMigraines (15-25%) (15-25%)

Others like Others like Cluster HeadachesCluster Headaches, , Neuralgia(<1%)Neuralgia(<1%)

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SHORT VS LONG DURATION SHORT VS LONG DURATION HEADACHESHEADACHES

< 4 HOURS< 4 HOURSIce Pick HeadachesIce Pick HeadachesCluster HeadachesCluster HeadachesNeuralgiasNeuralgias

> 4 HOURS> 4 HOURSMIGRAINESMIGRAINESTENSION HEADACHESTENSION HEADACHES

MEDICATION OVERUSE HAMEDICATION OVERUSE HA

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How to Recognise Tension How to Recognise Tension Headaches ?Headaches ?

Pressure, Like a band, Head in a vicePressure, Like a band, Head in a vice Usually all over the headUsually all over the head Sickness and Sensitivity to light and sound Sickness and Sensitivity to light and sound

is fairly uncommonis fairly uncommon Stressful event/ Worrying about tumourStressful event/ Worrying about tumour

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How to recognise Migraine ?How to recognise Migraine ?

Pulsating/ThrobbingPulsating/Throbbing Unilateral/Bilateral frontal/temporalUnilateral/Bilateral frontal/temporal Sickness and Sensitivity to Sickness and Sensitivity to

light/sound/smelllight/sound/smell Exacerbation with Physical activityExacerbation with Physical activity Lasting more than 4 hours unless a good Lasting more than 4 hours unless a good

analgesic response.analgesic response.

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TYPES OF MIGRAINETYPES OF MIGRAINE

Common Migraine (Migraine without Aura)Common Migraine (Migraine without Aura)

Classical Migraine (Migraine with Aura)Classical Migraine (Migraine with Aura)

Migrainous Aura without HeadachesMigrainous Aura without Headaches

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How to Recognise a Migraine Aura ?How to Recognise a Migraine Aura ?

Symptoms similar to a Transient Ischaemic Symptoms similar to a Transient Ischaemic Attack (MINI STROKE)Attack (MINI STROKE)

Young ageYoung age Family HistoryFamily History Gradual progression of symptomsGradual progression of symptoms Visual aura is commonestVisual aura is commonest

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Visual Visual AuraAura

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ScotomaScotoma

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Visual BlurringVisual Blurring

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How to recognise Cluster Headaches ?How to recognise Cluster Headaches ?

More common in Men (M:F = 6:1)More common in Men (M:F = 6:1) More common in Smokers (90%)More common in Smokers (90%) Excruciating HeadachesExcruciating Headaches 2-8 times per day each lasting 30-120 2-8 times per day each lasting 30-120

minutesminutes Strictly unilateral/frontal/around eyeballStrictly unilateral/frontal/around eyeball Runny Blood Shot and droopy eyeRunny Blood Shot and droopy eye Early morning attacksEarly morning attacks

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ClusterCluster HeadachesHeadaches

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How to Recognise Medication Overuse How to Recognise Medication Overuse Headaches ?Headaches ?

Usually cause Round the Clock Daily Usually cause Round the Clock Daily headaches (Chronic Daily Headaches)headaches (Chronic Daily Headaches)

Consumption of Painkillers for 15 or more Consumption of Painkillers for 15 or more days per month for more than 3 monthsdays per month for more than 3 months

More common with opiate analgesics, More common with opiate analgesics, ergotamine and triptansergotamine and triptans

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

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How to recognise Neuralgias ?How to recognise Neuralgias ?

Attacks are very short i.e., few secondsAttacks are very short i.e., few seconds Trigeminal Neuralgia is the commonestTrigeminal Neuralgia is the commonest Attacks precipitated by chewing, brushing, Attacks precipitated by chewing, brushing,

shaving and speakingshaving and speaking Mainly over cheeks / Jaw not around eyesMainly over cheeks / Jaw not around eyes

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Standard abortive Standard abortive therapytherapy

Migraine; How to manage?Migraine; How to manage?

Migraine; How to manage?Migraine; How to manage?

Identify any obvious triggers

Infrequent attacks• Acute treatment only

Frequent attacks• Acute and Preventative treatments

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

I WANNA TRY BOTOX NEXT

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

THANK YOUTHANK YOU

ANY QUESTIONSANY QUESTIONS

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