HEADACHES When to seek advice DR FAYYAZ AHMED

HEADACHES; When to seek advice? DR FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST 1/3/2022 1

LEARNING OUTCOME n n 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

HEADACHES n n 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 , 55% of Neurology in A & E (1) (2) 1. Weatherall M. , J RCP Edinb 2006; 36: 196 -200 2. Craig J. , Patterson V. , Roche L. , Jamison. J. , Accident and Emergency Neurology: time for a reappraisal? Health Trends, 1997, 29, 89 -91 1/3/2022 4

HEADACHES REQUIRING URGENT GP CONSULTATION Sudden onset of worst ever headache Headaches with fever/rash drowsiness Rapid progression of new onset headache New headache starting after age 50 Change in characteristics or pattern of longstanding headache 1/3/2022 6

HEADACHES REQUIRING SPECIALISTS’ INPUT n n Difficulty in establishing a diagnosis Migraine/Tension headache refractory to treatment Headaches requiring frequent analgesia Short lasting headaches/symptoms suggesting Cluster Headaches

PRIMARY VS SECONDARY HEADACHES n n Primary Headaches have no underlying cause and are mostly harmless and potentially treatable e. g. Migraine, Tension Headaches Secondary Headaches have an underlying cause and are still potentially treatable 1/3/2022 8

SECONDARY HEADACHES n 1. 2. 3. 1/3/2022 NON SERIOUS (Common ) Referred Headaches Medication Overuse Minor Head Injury 9

Causes of Referred Headaches n Eyes – Errors of Refraction n ENT – Sinuses n Teeth – Peridontal Disease n Jaw – Temporomandibular dysfunction n Neck – Degenerative Spinal Disease 1/3/2022 10

SECONDARY HEADACHES n 1. 2. 3. 4. 1/3/2022 Serious (< 1%) Brain Tumours Brain Haemorrhage Meningitis/Encephalitis Temporal Arteritis 11

PRIMARY HEADACHES n n Virtually All of them are Benign or Harmless Tension Headache is the commonest Migraine is the second most common Cluster Headaches and Neuralgias are uncommon but treatable 1/3/2022 12

PRIMARY HEADACHES n Tension Headaches (60 -75%) n Migraines (15 -25%) n Others like Cluster Headaches, Neuralgia(<1%) 1/3/2022 13

SHORT VS LONG DURATION HEADACHES n < 4 HOURS Ice Pick Headaches Cluster Headaches Neuralgias n > 4 HOURS MIGRAINES TENSION HEADACHES MEDICATION OVERUSE HA 1/3/2022 14

How to Recognise Tension Headaches ? n n Pressure, Like a band, Head in a vice Usually all over the head Sickness and Sensitivity to light and sound is fairly uncommon Stressful event/ Worrying about tumour 1/3/2022 15

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How to recognise Migraine ? n n n Pulsating/Throbbing Unilateral/Bilateral frontal/temporal Sickness and Sensitivity to light/sound/smell Exacerbation with Physical activity Lasting more than 4 hours unless a good analgesic response. 1/3/2022 17

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TYPES OF MIGRAINE n Common Migraine (Migraine without Aura) n Classical Migraine (Migraine with Aura) n Migrainous Aura without Headaches 1/3/2022 19

How to Recognise a Migraine Aura ? n n n Symptoms similar to a Transient Ischaemic Attack (MINI STROKE) Young age Family History Gradual progression of symptoms Visual aura is commonest 1/3/2022 20

Visual Aura 1/3/2022 21

Scotoma 1/3/2022 22

Visual Blurring 1/3/2022 23

How to recognise Cluster Headaches ? n n n n More common in Men (M: F = 6: 1) More common in Smokers (90%) Excruciating Headaches 2 -8 times per day each lasting 30 -120 minutes Strictly unilateral/frontal/around eyeball Runny Blood Shot and droopy eye Early morning attacks 1/3/2022 24

Cluster Headaches 1/3/2022 25

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How to Recognise Medication Overuse Headaches ? n n n Usually cause Round the Clock Daily headaches (Chronic Daily Headaches) Consumption of Painkillers for 15 or more days per month for more than 3 months More common with opiate analgesics, ergotamine and triptans 1/3/2022 28

Chronic Migraine n n n 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

How to recognise Neuralgias ? n n Attacks are very short i. e. , few seconds Trigeminal Neuralgia is the commonest Attacks precipitated by chewing, brushing, shaving and speaking Mainly over cheeks / Jaw not around eyes 1/3/2022 30

Migraine; How to manage? n Standard abortive therapy 1/3/2022 31

Migraine; How to manage? n Identify any obvious triggers n Infrequent attacks • Acute treatment only n Frequent attacks • Acute and Preventative treatments

ROLE OF SPECIALIST CLINICS n n n n 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 n n n 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 YOU ANY QUESTIONS 1/3/2022 37