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Diagnosis and management of primary headache

Diagnosis and management of primary headache. Steve Elliot GPwSI Headache. History taking in episodic headache History taking in chronic headache 3minute neurological examination Who to refer for scanning (Management of headache). “Listen to the patient. He is telling you the diagnosis”

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Diagnosis and management of primary headache

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  1. Diagnosis and management of primary headache Steve Elliot GPwSI Headache

  2. History taking in episodic headache • History taking in chronic headache • 3minute neurological examination • Who to refer for scanning • (Management of headache)

  3. “Listen to the patient. He is telling you the diagnosis” Sir William Osler (1849-1919)

  4. “The headache history has to be taken, not received” Professor Peter Goadsby

  5. Why does it matter? • Headache is not a diagnosis • Clear diagnostic criteria • Diagnosis before treatment • Disease specific treatments

  6. Guatama Buddha 563-483 BCHow to relieve suffering

  7. 8 questions - the way to end suffering in headache • Location? • Character? • Severity? • Aggravation by movement? • Nausea/vomiting? • Photophobia? • Phonophobia? • Duration?

  8. IHS tension headache 2 of • Bilateral • Pressing./tightening/non pulsating quality • Mild to moderate intensity • Not aggravated by movement No more than 1 of • Nausea/vomiting • Phonphobia or photophobia Duration 30minutes to 7days

  9. IHS migraine Need 2 out of: • Unilateral • Moderate-severe • Throbbing • Worse with movement Need 1 of • Nausea and/or vomiting • Photophobia and phonophobia Duration 4-72 hours

  10. SIGN guidelines “Neuroimaging is not indicated in patients with a clear history of migraine,without red features for potential secondary headache,and a normal neurological examination”

  11. Cluster headache • Side locked unilateral • Peircing /drilling/grinding • Very severe • Not worse with movement • Possibly nausea/vomiting • Possibly unilateral photophobia • Possible phonophobia • 15-180 minutes duration • Autonomic symptoms • Restless

  12. Landmark study • 1203 patients • GP diagnosis of primary headache • Headache diary for 3months • Diaries analysed by blinded assessors Findings: • 94% migraine or probable migraine • 82% “tension type headache” had migraine

  13. “Brain attack” • Trigger – Dorsal pons • Prodrome - Hypothalmus • Aura – Cerebral cortex • Peripheral sensitisation – Cranial vasculature • Central sensitisation – Thalamus • Nausea/vomiting- Area Postrema • Autonomic symptoms – Parasympathetic system • Neck pain – Sensitisation of C2/C3

  14. Why me? • Blame your parents • Chemical imbalance • Your brain is different • Symptoms between attacks

  15. Chronic headache • 2-3% of population have headache on more days than don’t • Half of above have medication overuse • 2%/year migraine transforms to chronic • Most preceded by episodic headache • Co-mordidities anxiety,depression,obesity • Difficult to manage

  16. Causes chronic daily headache Primary headaches • Chronic tension type headache • Chronic migraine • Chronic cluster headache • Medication overuse headache • New daily persistent headache • Hemicrania continua

  17. History in chronic headache • Pattern Low grade all time? Low grade with exacerbations? Short lasting frequent? • Stable or progressive? • 8 questions • Medication including OTC? • Caffeine consumption? • Exclude red flags

  18. What not to miss • Idiopathic intracranial hypertension • Low pressure headache • Giant cell arteritis • Other secondary headache REMEMBER • High pressure headache WORSE on lying flat • Low pressure headache BETTER lying flat

  19. Don’t forget • BP • Palpate temporal arteries >50 • ESR/CRP >50 • DOCUMENT WHAT YOU DO

  20. Acute medication in migraine • Paracetamol • Aspirin 900mg • Naproxen 500mg • Domperidone if nausea • Consider suppositories • Almotriptan 12.5mg • Other triptan if Almotriptan ineffective • Zolmitriptan nasal spray • Sumatriptan injection

  21. Prophylaxis • Propranolol 80-240mg • Amitriptyline 10-100mg • Pizotifen if young • Topiramate or Epilim • Take 6-8 weeks to kick in • See regularly

  22. Don'ts in migraine treatment • Over the counter • Opioids • Caffeine • Migraleave • Analgesia more than 2-3 days per week

  23. Sir William Osler again “One of the first duties of the physicians to educate the masses not to take medicines”

  24. Medication overuse headache • Headache >15 day per month • Intake of following for 3months Simple analgesia >15 days per month Or Opioids/triptans/combination analgesia >10 days per month • Headache resolves or returns to previous pattern within 2months of discontinuation of analgesia

  25. What do you do when you get a headache? • Stay still =Migraine • Pace up and down = Cluster • Take tablet = Medication overuse

  26. Management of chronic headache • Exclude red flags • Establish phenotype • Lifestyle measures • Avoid caffeine • Stop analgesia • (Occasional Naproxen) • Start prophylaxis according to phenotype • Regular follow up

  27. “ The very first step towards success in any occupation is to become interested in it” Sir William Osler (1849-1919) Canadian Physician

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