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Diagnosis and management of primary headaches-BASH guidelines

Diagnosis and management of primary headaches-BASH guidelines. Aisha Bhaiyat 14 June 2011. Aim to cover the following:. Red flags Migraines Tension type headache Cluster headaches Medication overuse headaches. Classification of headaches. Primary - migraines, TTH, cluster

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Diagnosis and management of primary headaches-BASH guidelines

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  1. Diagnosis and management of primary headaches-BASH guidelines Aisha Bhaiyat 14 June 2011

  2. Aim to cover the following: • Red flags • Migraines • Tension type headache • Cluster headaches • Medication overuse headaches

  3. Classification of headaches • Primary - migraines, TTH, cluster • Secondary – trauma, vascular, ICP (BIH or tumour, substance or its withdrawal (CO, EtOH, medication), extracranial (acute glaucoma, sinusitis, teeth) • Neuralgias - trigeminal

  4. Red Flags • New/unexpected headache in an individual • Thunderclap headache • Atypical aura (motor weakness or longer than 1 hour) • First aura on starting COCP • New onset headache in over 50’s or under 10’s • Persistent am headache with nausea • Progressive headaches • Postural headaches • New onset headache in those with PMH of cancer/HIV

  5. Consider serious causes • Intracranial tumours • SAH • Meningitis • Temporal arteritis • Primary angle closure glaucoma • Idiopathic intracranial hypertension • Carbon monoxide poisoning

  6. History • Timing-onset, frequency, duration, why present now • Character-site, radiation, quality, intensity, associated symptoms • Cause-prediposing/trigger, aggravating/relieving, FH • Between attacks-well/residual/persisting symptoms. ICE

  7. Migraine without aura-diagnosis IHS criteria. At least 5 attack fulfilling the following: • Duration- lasting 4-72 hours • Character, at least 2 of the following; unilateral, pulsating, mod/severe, worse with physical activity • Associations-nausea/vomiting or photophobia/phonophobia • Not due to any other secondary cause

  8. Migraine with aura-diagnosis • Aura-progressive, last 5-60 minutes prior to headache. Hemianopic disturbance/spreading scintillating scotoma. Not blurring or spots. Can include other focal neuroligical symptoms egparasthesia, dysphasia • Consider TIA if new onset in elderly patients • Refer to specialist if aura includes motor weakness, persists after resolution of headache or occur daily.

  9. Scintillating scotoma

  10. Tension type headaches-diagnosis • Usually generalised, can be unilateral • Pressure/tightness around the head • Radiate from the neck • Lasts a few hours • No associated features

  11. Cluster headaches-diagnosis • M:F 6:1, over 20’s, smokers • Occurs same time each day, last 30-60 mins, 6-12 wks, every 1-2 years, at the same time of year • Intense, unilateral pain • Autonomic features: ipsilateralconjuntival injection, lacrimation, rhinorrhoea, blocked nose and ptosis

  12. Medication overuse headache-diagnosis • Caffeine and codeine are prime causes. Although simple analgesia can be causes. • Low doses daily is worse that high dose weekly. Detailed analgesia history. • Headache sufferer for years, using analgesia. • Headache worse in the morning and with physical activity. • Patient requesting stronger and stronger analgesia

  13. Physical examination • BP-patient expectation, HT, migraine prophylaxis can cause HT • Fundoscopy-papilloedema • Head and neck for muscle tenderness • CNS exam - Not specified in the guidelines • Investigations-only if a secondary cause suspected

  14. Migraine-management • Aim is to control symptoms sufficiently to not impact on patients life ie cure unlikely. • Trigger factor avoidance-eat reg, sleep • Drug treatment of acute symptoms • Prophylaxis

  15. Migraine-acute Criteria for progressing to next step: Failure on 3 occassions • Step 1: po NSAID +/- po/buccalantiemtic • Step 2: pr NSAID +/- pr antiemetic • Step 3: antimigraine drugs If step 3 fails-review diagnosis, compliance and how medication is being used. • Step 4: Combine step 3 with step 1 or 2 Do not use opiates-gastric stasis; risk of medication overuse headache

  16. Antimigraine drugs Triptans • PO/Melts/Subcut • At the start of headache, whilst mild pain • Ineffective during aura • Can cause rebound migraine in 20-50% within 48 hours Ergotamine • Longer duration of action; Less likely to have rebound migraine • More toxic and med overuse headaches

  17. CI to step 3 • Uncontrolled HT • Risk factors for vascular disease • Age under 12 years

  18. Migraine-prophylaxis • Indication-frequent/inadequate control/triptan 10 or more days a month/analgesia 15 or more days a month/triptans or analgesia 2 or more days a wk • Drugs should be titrated up slowly (avoid SE) and not deemed ineffective too early; trial should last 6-8/52 • Effective drug should be used for 4-6/12 and withdrawal tapered over 2-3/52

  19. Migraine prophylax-1st line • B-blockers-atenolol 25-100mg bd, CI asthma/CCF/PVD/depression • Amitryptiline 10-150mg when migraine coexist with TTH, sleep probs, chronic pain, or depression

  20. Migraine prophylaxis-2nd and 3rd line • Topiramate (acute myopia/glaucoma) 25-50 mg bd • Valproate 300-1000mg bd (FBC at starting, and LBP for 6/12) • 3rd line: gabapentin, methysergide(risk of fibrosis), b-blocker + amitryptiline combined

  21. Tension type headaches • Reassurance • Ensure medication is not overused, risk of developing medication overuse headaches. • Exercise + relaxation • NSAIDS, less than 2/7 per week • If frequent, break cycle by giving regular naproxen for 3/52, course not to be repeated • If chronic-Amitryptiline • Avoid opiates • Pain clinics

  22. Cluster headaches • Reassurance • Drugs + oxygen • Both symptomatic + prophylaxis required • Avoid EtOHand smoking

  23. Cluster headaches-drugs • Symptomatic: Sumitriptan 6mg s/c, oxygen 10-15l/min 10-20 mins • Prophylaxis:Verapamil (ECG)/prednisalone 60-100mg od (2-5/7 and reduce by 10mg every 2-3/7)/ Lithium (serum monitoring)/methysergide (risk-fibrosis)/ergotamine • Continue until headache free for 14 day (except steroids) and then gradually reduce.

  24. Med overuse headaches • Withdrawal • Recovery • Review the original headache disorder (which may return after recovery from withdrawal) • Prevent relapse

  25. Med overuse headaches • All patients with headache should be educated about medication overuse • Withdrawal-symptoms worsen, sick leave for 1-2 wks, good hydration. • Ergot/triptan/non opioids stopped abruptly. Withdrawal headache last 2-10/7. May have nausea/vomiting/low BP/Hi HR/sleep probs/anxiety. • Opioids slowly-consider referring to drug and etoh services. • Withdrawal headache-reg naproxen for 3/52, course not to be repeated.

  26. Summary • Consider serious causes incl CO poisoning • Remember to check BP and fundoscopy • Avoid prescribing opioids • Advice re lifestyle and risks of med overuse • If occurring frequently, consider regular naproxen for 3/52 to break cycle or prophylaxis treatment • Consider chronic pain management options • Further information www.bash.org.uk

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