HEADACHES IMPORTANCE OF AN ACCURATE DIAGNOSIS FAYYAZ AHMED

HEADACHES; IMPORTANCE OF AN ACCURATE DIAGNOSIS FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST 1/3/2022 1

To set the scene. . . l “[Migraine] is a malady of which the student gains little practical knowledge in the course of his hospital work, unless he is so unhappy as to learn from the most effective of all instructors, personal suffering. . . It is common enough, but seems, to most of its subjects, by long experience so much an inevitable part of life that few seek relief. ” William Gowers (1906) l “A doctor who cannot take a good history and a patient who cannot give one are danger of giving and receiving bad treatment” 1/3/2022 2 Anonymous

English, which can express the thoughts of Hamlet and the Tragedy of Lear has no words for the shiver and the headache… The merest schoolgirl, when she falls in Love, has Shakespeare or Keats to speak her mind for her, but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry. Virginia Woolf ‘On being ill’ 1930 p 6 -7 1/3/2022 3

HEADACHE a Symptom Many causes: Some structural Some perhaps pharmacological Some psychological 1/3/2022 4

The History is paramount History is taken not given (Peter Goadsby) Clinical examination is usually normal Investigations can only exclude specific causes 1/3/2022 5

CASE 1 l 28 Male, Smoker, Manager - No PMH Jul 07 - Headaches – 3 months – GP - tension headache – Amitriptyline l Oct 07 – No better – ? Migraine – Propranolol l Feb 08 – No better – ? Depressed – Paroxetine l Jul 08 – No better – Refer to Neurologist l Aug 08 – Stopped working – couldn’t cope l 1/3/2022 6

CASE 1 - contd Dec 08 – Neurologist (Registrar) l Left peri-orbital /maxillary continuous pain l Lacrimation and Rhinorrhea l ? Sinus related l MRI l ENT opinion l Mar 09 – ENT l No ENT related problem l MRI aberrant vessel possible touching left trigeminal l 1/3/2022 7

CASE 1 - contd l Jul 09 Neurologist –consultant l Diagnosis – Trigeminal Neuralgia l Carbamazepine l Sep 09 l Rash with Carbamazepine l Pain worse l Gabapentin (tried up to 3600 mg – no response) 1/3/2022 8

CASE 1 - contd l Jan 10 – Neurologist l TN refractory to Rx l Refer Neurosurgeon l May 10 – Neurosurgeon l Offered Microvascular decompression l Patient desparate l Oct 10 – Surgery 1/3/2022 9

CASE 1 - contd l Jan 11 – Neurosurgeon l No better l Headache Clinic l May 11 – Headache Clinic l Diagnosed Chronic Cluster Headache l Steroid – Oxygen – Methysergide l Pain free 1/3/2022 10

CASE 1 - contd l Patient Quotes “ You’ve given me a new life” “ Children have got their daddy back” 1/3/2022 11

CASE 2 l l l 35 Female, administrator, no PMH May 09 – Pain Right Face Jun 09 – GP – Ibuprofen Jul 09 – No better – Dentist – R 2 nd molar taken out Aug 09 – No better – R 1 st molar taken out Sep 09 – No better – Maxface 1/3/2022 12

CASE 2 - contd Feb 10 – Maxface l No maxface problem l Neurologist l Aug 10 – Neurologist (Registrar) l Atypical Facial Pain – Amitriptyline l MRI - Normal l Dec 10 l Neurology Review l No better – Headache Clinic l 1/3/2022 13

CASE 2 - contd l Apr 11 – Headache Clinic l Diagnosis – Trigeminal Neuralgia l Carbamazepine – Pain free within 72 hours 1/3/2022 14

Misdiagnosis of Cluster Headache Time to diagnosis 2. 6 yrs (Bahra & Goadsby 2004) l See a mean of 3 GP’s before referral l (Bahra & Goadsby 2004) Not considered because of gender, smoking status (Wheeler Carrazana 2001) l 34% referred to dentist and 33% to ENT l (Van Vilet et al, 2003) l 1/3/2022 Misdiagnosed as sinus pain, trigeminal neuralgia, dental pain (Van Alboom et al, 2009) 15

Other misdiagnosed headaches l Trigeminal Neuralgia as dental problem or l as TMJ disorder l l Medication overuse Headaches l Chronic Migraine l The rare autonomic cephalalgias i. e. SUNCT, SUNA 1/3/2022 16

HEADACHE DISORDERS ARE UBIQUITOUS, PREVALENT, DISABLING AND LARGELY TREATABLE, BUT UNDER-RECOGNISED, UNDERDIAGNOSED AND UNDER-TREATED Steiner et al J Headache Pain (2011) 12(5); 501 1/3/2022 17

THANKS Questions? 1/3/2022 18