Consider sinister headache Patient presenting with headache Q

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Consider sinister headache Patient presenting with headache Q 1. Headache impact low ATTH High

Consider sinister headache Patient presenting with headache Q 1. Headache impact low ATTH High Q 2. No. of headache days per month Migraine/CDH > 15 < 15 Consider short-lasting headaches Chronic headache Q 3. Analgesic days/week <2 Not analgesic dependent >2 Analgesic dependent Migraine Q 4. Reversible sensory symptoms Headache Pathways David Yes. Kernick No With aura St Thomas Health Without Centreaura Exeter

To a man with a hammer Everything is a nail

To a man with a hammer Everything is a nail

All headache is migraine

All headache is migraine

Classifying headache

Classifying headache

IHS Headache classification Primary n Migraine n Tension type n Cluster Secondary n n

IHS Headache classification Primary n Migraine n Tension type n Cluster Secondary n n n n Traumatic Vascular Non-vascular Substance induced Infection Metabolic Facial structures

What do people think when they present with headache? n I need glasses (<1%

What do people think when they present with headache? n I need glasses (<1% headache due to undiagnosed refractive errors) n Its my blood pressure n I have a tumour

What do GPs think patients have? Kernick 2009

What do GPs think patients have? Kernick 2009

What do patients have when they present to GP with headache? n 80% migraine

What do patients have when they present to GP with headache? n 80% migraine n 15% Tension type headache n 5% secondary headache

Is it a tumour?

Is it a tumour?

Red Flags Probability of significant pathology >1%. Need urgent investigation

Red Flags Probability of significant pathology >1%. Need urgent investigation

Orange Flags Headache presentations where probability is likely to be 0. 1% and 1%.

Orange Flags Headache presentations where probability is likely to be 0. 1% and 1%. Need careful monitoring

Yellow Flags Probability of underlying pathology is <0. 1% but above background. Needs appropriate

Yellow Flags Probability of underlying pathology is <0. 1% but above background. Needs appropriate management and follow up there are no green flags

Headache and tumour n Headache prevalence with tumour 70%+ n Headache at presentation 50%

Headache and tumour n Headache prevalence with tumour 70%+ n Headache at presentation 50% n Headache alone at presentation 10% (Iverson 1987)

Population 100, 000 adults each year: n 220, 000 population headaches n 4000 GP

Population 100, 000 adults each year: n 220, 000 population headaches n 4000 GP headaches n 1 tumour will present as isolated headache

Risk of brain tumour and headache presenting to primary care (Kernick 2008) Headache overall

Risk of brain tumour and headache presenting to primary care (Kernick 2008) Headache overall – 0. 09% Non headache - 0. 02% Risk % All ages Undifferentiated headache 0. 15% Primary headache 0. 045%

Risk of brain tumour and headache presenting to primary care (Kernick 2008) Risk %

Risk of brain tumour and headache presenting to primary care (Kernick 2008) Risk % Overall Undifferentiated headache 0. 15% Under 50 0. 08% Over 50 0. 28%

Scan when advantages over weigh disadvantages The advantages: n Better management improved quantity and

Scan when advantages over weigh disadvantages The advantages: n Better management improved quantity and quality of life if positive n. Allay anxiety - reassurance if negative

The disadvantages n Resource implications n Exposure radiation with CAT scan n Exposes incidental

The disadvantages n Resource implications n Exposure radiation with CAT scan n Exposes incidental abnormalities Population 0. 6 - 6% average 2. 7% (Morris 2009) GP requests 10% (Thomas 2010)

Luftwaffe pilots (n-2370) Weber 2006 n 93% normal (25% variations of norm) n 6.

Luftwaffe pilots (n-2370) Weber 2006 n 93% normal (25% variations of norm) n 6. 7% abnormalities n 56 cysts; 13 vascular abnormalities; 4 adenomas; 4 tumours

In reality the inputs are complex n Limited poor quality evidence base n Expert

In reality the inputs are complex n Limited poor quality evidence base n Expert opinion n Medico-legal case law n Patient-doctor characteristics and approach to uncertainty n Organisational factors

Do something now n Meningitis n Thunderclap headache n Temporal arteritis n Carbon monoxide

Do something now n Meningitis n Thunderclap headache n Temporal arteritis n Carbon monoxide n Malignant hypertension

Do something soon n Headache with abnormal neurological examination n Headache with recent history

Do something soon n Headache with abnormal neurological examination n Headache with recent history of fits n Headache with orgasm (first presentation – now) n History of cancer elsewhere or or HIV n Exercise induced headache (not pre orgasmic) n Precipitated by Valsalva manoeuvre, cough

Keep close eye and think carefully n Headache with significant change in pattern n

Keep close eye and think carefully n Headache with significant change in pattern n Awakes from sleep n New headache over 50 years n New Cluster headache n Worse on standing n If a primary headache diagnosis has not emerged in an isolated headache after 6 -8 weeks

Diagnose a primary headache n Exclude medication overuse headache n Diagnose migraine, Tension type

Diagnose a primary headache n Exclude medication overuse headache n Diagnose migraine, Tension type or Cluster

Medication overuse headache Headache intensity Withdrawal of all analgesia Increased frequency of headache, associated

Medication overuse headache Headache intensity Withdrawal of all analgesia Increased frequency of headache, associated with increased frequency of analgesia use. Daily headache with spikes of more severe pain Migraine attacks Frequent ‘daily’ headaches Return of episodic headache

Simple Diagnostic aid n Migraine – have to lie down n Tension headache –

Simple Diagnostic aid n Migraine – have to lie down n Tension headache – can keep going n Cluster Headache – have to bang head

Formal Migraine n 4 -72 hours n Two of : unilateral, pulsating, moderate or

Formal Migraine n 4 -72 hours n Two of : unilateral, pulsating, moderate or severe pain, aggregation by physical activity. n At least one of: nausea/vomiting, photophobia, phonophobia.

Other diagnostic pointers for migraine n I feel nauseated n I don’t like light

Other diagnostic pointers for migraine n I feel nauseated n I don’t like light or sound n Movement makes things worse

Activation anywhere in the system can lead to output in any other part of

Activation anywhere in the system can lead to output in any other part of the system and vici versa

Formal Tension Type n 30 minutes – 7 days. n 2 of : bilateral,

Formal Tension Type n 30 minutes – 7 days. n 2 of : bilateral, non-pulsating, mild/moderate, not aggravated by activity. n No nausea, vomiting, photophobia, phonophobia.

AURA Thalamus + Mid Brain structures Medication overuse headache Tension type headache Hypothalamus CLUSTER

AURA Thalamus + Mid Brain structures Medication overuse headache Tension type headache Hypothalamus CLUSTER CERVICAL NUCLEI MIGRAINE CENTRE Headache model

Migraine treatment Acute n Paracetamol/Asp/Domperidone n Rectal NSAI/Domperidone n Triptan

Migraine treatment Acute n Paracetamol/Asp/Domperidone n Rectal NSAI/Domperidone n Triptan

The Triptans n Tablets, melts, nasal spray, injection. n Side effects n Failure response

The Triptans n Tablets, melts, nasal spray, injection. n Side effects n Failure response is not a class effect n Treat onset of pain n Over 65 years?

Migraine prevention n Beta blocker n Amitriptyline n Topiramate

Migraine prevention n Beta blocker n Amitriptyline n Topiramate

GPw. SI? n Not secondary headache exception medication overuse headache n Unsure of diagnosis

GPw. SI? n Not secondary headache exception medication overuse headache n Unsure of diagnosis if red flag excluded n Primary headache difficult to treat n ? New cluster

Five key questions n How many types of headache do you get? n Is

Five key questions n How many types of headache do you get? n Is there a family history of troublesome headache? n What pain killers are you taking? n What is the impact of your headache? n What do you think is causing it?

Two key examinations n Blood pressure n Fundoscopy

Two key examinations n Blood pressure n Fundoscopy

One key delaying tactic n Go away and keep a diary n Make a

One key delaying tactic n Go away and keep a diary n Make a double appointment next time