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Primary Care Management of Headache

Primary Care Management of Headache. Dr Mark Cossburn Consultant Neurologist. Aims of the talk. To highlight that headache is: Common Not usually sinister Diagnosable Manageable Not…………. Common. 3.2%. 5.1%. 2.1%. 3.2%. 5.1%. 2.1%. 15.2%. 3.2%. 5.1%. 2.1%. 15.2%.

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Primary Care Management of Headache

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  1. Primary Care Management of Headache Dr Mark Cossburn Consultant Neurologist

  2. Aims of the talk To highlight that headache is: • Common • Not usually sinister • Diagnosable • Manageable • Not…………

  3. Common

  4. 3.2% 5.1% 2.1%

  5. 3.2% 5.1% 2.1% 15.2%

  6. 3.2% 5.1% 2.1% 15.2%

  7. Key headache facts • 99%: at least one moderate headache • 8 million people living with migraine • 190,000 attacks are experienced every day, with three quarters of people affected reporting disability

  8. Causes of isolated headache Migraine Tension Type Systemic illness Medication Overuse Rare primary Cluster

  9. Causes of isolated headache Migraine Tension Type Medication Overuse Cluster

  10. Pathway to management Initial Assessment Review and Diagnosis Definitive Treatment Review and Revise

  11. Initial consultation • Information gathering • Description of event • Antecedents • Consequences • Fears • Targeted neurological examination • Information giving

  12. Red Flags in headache • Thunderclap onset: First and worst • New onset after age 50 • Posture/exercise/valsalva provoked • Wakes from sleep • Jaw claudication / temporal tenderness • Focal signs • Cognitive decline • History of malignancy or immunosuppression • Severe inter-current systemic illness

  13. Establish impact and pattern • Headache diary • 2-4 weeks of daily information on headache • Headache severity score

  14. Acute management

  15. Acute management

  16. Acute management

  17. Acute headache treatment

  18. Aspirin vs Sumatriptan Fig. 1 Results for headache relief (efficacy parameters:pain-relief at 2 h, pain-free at 2 h, sustained pain-free till 24 h); bars indicate 95 %-confidence intervals; no significant differences between aspirin and sumatriptan Efficacy and safety of 1,000mg effervescent aspirin: individual patient data meta-analysis of three trials in migraine headache and migraine accompanying symptoms. Lampl et al. J Neurol (2007) 254:705–712

  19. Medication Overuse • Common 1-2% • Medication overuse > 3 months • Ergots, Triptans, Opioids: 10 days/month • Paracetamol, NSAIDS: 15 days/months • Combination: 10 days/month

  20. Just stop it? • Evidence that treatment is needed • Prednisolone 60-100mg daily 8 days • Amitriptylline 50mg daily • Topiramate up to 200mg daily • Especially if have migraine • Withdrawal syndrome • Anxiety, hypotension, sweating, nausea headache, restlessness, sleeplessness • 1-4 weeks • Relapse 23% at 2 months 44% at 4 years

  21. Prophylaxis

  22. Problems with migraine trials

  23. Menstural Migraine • True menstrual migraine • Exclusively 2 days prior to 3 days post onset • No aura • All migraine more frequent around menstruation • Amenorrhoeic women have fewer migraines • Treatment options • Ovulation suppression • Topical oestrogen • Cyclical prophylaxis

  24. Summary Commence Definitive Treatment Review, Revise, Individualise Review and Diagnose

  25. Initial consultation Making a diagnosis Acute treatment Prophylactic treatment Additional measures Obtain full history including: Triggers Aura Onset Evolution Duration Associated symptoms Pattern Frequency PMH DH (inc OCP & OTC) Examine: Clinical Brief Neuro Fundoscopy BP Exclude red flags (see box) Evaluate: Headache diary HIT-6 score Review: 2-4 weeks Tension Type Headache Bilateral Mild to moderate pain No nausea Examination normal HIT-6<55 Migraine Lateralised Nausea Photo/phonophobia (even between attacks) Family history Aura in 15-33% HIT-6 >55 Cluster Headache Rapid onset Lateralised severe 1-8 per day Agitated in attacks Autonomic features HIT-6 >55 Tension 1. Paracetamol 1g 2. Aspirin 1g Medication to be given when headache is of moderate severity 1. Amitriptylline 25-150mg daily 2. Mirtazepine 30mg daily 3. Venlafaxine 150mg daily Recommend exercise Consider co-existing: OSA, CFS, bruxism, depression, MOH Direct patient to www.migrainetrust.org Migraine 1. Paracetamol 1g 2. Aspirin 900mg 3. Sumatriptan 50-100mg (add Naproxen500mg if recurrent/prolonged) 4. Almotriptan 12.5mg 1. Propranolol 80 -240mg daily 2. Sodium Valproate 800-1500mg daily 3. Topiramate 50-200mg daily Use an anti-emetic (metaclopramide or domperidone) po or pr if nausea is prominent www.migrainetrust.org For information Cluster 1. Sumatriptan 6mg sc If not tolerated… 2. Zolmitriptan 5mg nasally 3. High flow O2 (7-12l/min) 1. Verapamil 240 – 960mg daily Patient needs ECG to calculate QTc pre/post every dose change Direct patient to: www.ouchuk.org For information, support and advice Advise smoking Cessation Consider MRI Red Flags (presence requires discussion and urgent referral) New onset / change in patients >50 years , Postural / exercise / valsalva provoked Wakes patient from sleep, History of malignancy or immune suppression, aura<5 or > 60m Jaw claudication / temporal tenderness, focal signs / cognitive decline, Thunderclap

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