Headaches from a GP Perspective

Headache

Headache

• Headache affects 75% of population per year (45 million people) and 25% of Neurology OP referrals

• Daily headache affects 4% of population• On any day 90,000 people are absent from work or

school because of headache• Migraine alone accounts for 20 million lost work

or school days per year• Cost of migraine to the economy in UK £1 billion

per year

Most headaches are due to:

• Tension-type headache 70%

• Migraine 14%

Classification of headache 1. Primary headache (from IHS 2003)

(must have characteristic or benign features without abnormal neurological signs)

1. Migraine2. Tension-type headache3. Cluster headache and other trigeminal autonomic cephalgias4. Other headache not associated with structural lesion

Classification of headache 2. Secondary headache(from IHS 2003)

5. Head or neck trauma 6. Cranial or cervical vascular disorders7. Non-vascular intracranial disorders8. Substances or their withdrawal9. Infection10. Disorder of homeostasis11. Eye, ENT, orofacial, or cervical disorders12. Psychiatric disorder13. Cranial neuralgias and central causes of facial pain14. Headache not classifiable

Migraine characteristics

• Attacks of headache lasting 4 to 72 hours• Nausea and/or vomiting• Intolerance of light• Intolerance of noise• Recurrent attacks• Visual or neurological aura lasting 6 – 60 mins• Consistent trigger

A few headache cases

Headache - Danger Signals

• First and worst headache• Association with

– loss of consciousness or collapses– non-migrainous visual disturbances or focal

neurological signs– fever or rash

• Sudden headache with vomiting and/or loss of consciousness at onset

• Neck stiffness• Jaw claudication (pts over 50)

Headache - Concerning features

• New onset headache after age 50• Genuinely increasing frequency and severity• Waking patient from sleep• Unresponsive to treatment• Always on same side• Following head trauma• Precipitated by exertion • New headache in patients:

– On anticoagulants – With HIV or cancer

Diagnosis

• Careful history

• Examination– to exclude focal neurological signs or RIP– evidence of anxiety, tension or depression

Diagnosis 1 – HistoryCareful attention to detail

• Recognition and assessment of each type of headache• Details of onset, duration, pattern and progression. Night-

time headache• Associated features

– Blackouts, collapses, jaw claudication, visual disturbances, incontinence

• Triggers, aggravating and relieving factors• Effect on usual activities• Treatments tried• Lifestyle, work and home stress, anxieties• Other relevant medical history• Drugs, alcohol, medication

Diagnosis 2 - Examination

• Systemic disease, e.g. fever, BP, evidence of cancer• To exclude focal neurological signs or RIP

• Visual field loss• Papilloedema• Cranial nerve palsies especially 3rd and 6th• Lateralised limb weakness• Abnormal reflexes and extensor plantars• Ataxia• Abnormal gait

• Look for evidence of anxiety, tension or depression

Investigations

• None may be necessary

• Investigation of systemic disease if suspected

• ESR & CRP if GCA suspected

• Brain imaging– if structural lesion suspected– for reassurance (patient, relatives, doctor!)

Frishberg et al 1994 - The utility of neuroimaging in the evaluation of headache in patients with normal neurological examinations. Review of 23 studies 1.

Migraine Unspecified headacheNo. % No. %

Total scans 897 100 1825 100Tumour 3 0.3 21 1AVM 1 0.1 6 0.3Hydrocephalus 8 0.4Aneurysm 3 0.2Subdural haem. 5 0.3

Headache LiteratureElrington (1999) - 1000 headaches 1

• Ages 8 - 87• Tension-type headache 34%• Migraine 26%• Psychiatric (mainly depression) 12%• Analgesic misuse 9%

Headache LiteratureElrington (1999) - 1000 headaches 2

• Secondary headaches– Mass lesion 1% (11)– SAH 0.7%– Idiopathic intracranial hypertension 0.2%– Giant cell arteritis 0.1%

• Clinical features predictive of abnormal imaging– thunderclap headache– papilloedema– ataxia

AAN Guidelines on imaging in headache1994

“In adult patients with recurrent headaches that have been defined as migraine including those with visual aura, with no recent change in pattern, no history of seizures and no other focal neurological signs and symptoms, the routine use of neuroimaging is not warranted. In patients with atypical headache patterns, a history of seizures or focal neurological signs or symptoms, CT or MRI may be indicated.”

Indications for referral?

1. Where specialist diagnosis is required

2. Clincal features suggest significant or serious neurological disease

3. Failure to respond to appropriate adequate treatment

4. Patient at high risk of serious disease

5. Reassurance

Indications for referral

1. Where specialist diagnosis is required• Unclear clinical features• Imaging required

2. Clincal features suggest significant or serious neurological disease1. Progressive or sinister headache symptoms2. Associated neurological symptoms (e.g. seizures, blackouts,

collapses)3. Abnormal neurological signs

3. Failure to respond to appropriate adequate treatment

4. Patient at higher risk of serious disease1. Cancer patients2. New headache in older patients

5. ?reassurance

Where to refer?

A&E/ACU Headache Clinic Neurology Clinic

Very short history suggesting

catastrophic or acute life-threatening

disease. e.g meningitis, SAH, ICH, encephalitis

Diagnosis and advice on management in

primary care of patients whose main problem is headache

Diagnosis and management of

patients with primarily neurological diseases

who cannot be managed in primary

care

Headache Clinic

Headache Clinic581 patients

34 (6%)Analgesic misuse

12 (2%)Non-classifiable

7 (1%)Face, Neck, Ears, Neuralgias

5 (1%)*Non-vascular intracranial disorders (incl tumours)

5 (1%)Vascular

5 (1%)Trauma

14 (2%)Other non-structural

16 (3%)Cluster

229 (39%)Tension-type

199 (34%)Migraine

Headache Clinic 581 patients Non-vascular intracranial disorders

• Intracranial tumour 1

• BIH 2

• Aqueduct stenosis 1

• Other 1

What is the outcome of investigation?

• Headache Clinic 581 patients

• CT 239

• Relevant abnormality 2

Management of Tension-Type Headache and Migraine

Management

• Accurate diagnosis• Clear explanation• Discuss environmental factors• General advice

– diet, coffee, alcohol, lifestyle, use of analgesics– Stress and anxiety management– relaxation

• Specific treatment

Management of Tension-type headache

• Lifestyle issues– work-home-leisure

balance

– exercise

– sleep

• Physical measures– relaxation

– physio

– self-help

• Drugs– limited simple

analgesics– amitriptyline– SSRIs– others

“Wolcott’s instant pain annihilator”

Acute attacks of Migraine

• Early analgesics– Aspirin 600-900mg– Ibuprofen 400mg– Paracetamol 1G

• Analgesics plus antiemetics– Metoclopramide– Buccastem

• Triptans– Rizatriptan 10mg– Almotriptan 121.5mg– Eletriptan 40-80mg

Prevention of Migraine

• Consider if 2 or more attacks per month– Beta-blockers– Pizotifen– Amitriptyline– Venlafaxine– Valproate– Topiramate– Gabapentin

Headache Guidelines

• www.bash.org.uk

• www.sign.ac.uk