Steve ElliotGPwSI Headache

History taking in episodic headache

History taking in chronic headache

3minute neurological examinationWho to refer for scanning(Management of headache)

“Listen to the patient. He is telling you the diagnosis”

Sir William Osler (1849-1919)

“The headache history has to be taken, not received”

Professor Peter Goadsby

Why does it matter?Headache is not a diagnosisClear diagnostic criteriaDiagnosis before treatmentDisease specific treatments

Guatama Buddha 563-483 BCHow to relieve suffering

8 questions - the way to end suffering in headacheLocation?Character?Severity?Aggravation by movement?Nausea/vomiting?Photophobia?Phonophobia?Duration?

IHS tension headache2 ofBilateralPressing./tightening/non pulsating qualityMild to moderate intensityNot aggravated by movementNo more than 1 ofNausea/vomitingPhonphobia or photophobiaDuration 30minutes to 7days

IHS migraineNeed 2 out of:UnilateralModerate-severeThrobbingWorse with movementNeed 1 ofNausea and/or vomitingPhotophobia and phonophobiaDuration 4-72 hours

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”

Cluster headacheSide locked unilateralPeircing /drilling/grindingVery severeNot worse with movementPossibly nausea/vomitingPossibly unilateral photophobiaPossible phonophobia15-180 minutes durationAutonomic symptomsRestless

Landmark study1203 patientsGP diagnosis of primary headacheHeadache diary for 3monthsDiaries analysed by blinded assessorsFindings:94% migraine or probable migraine82% “tension type headache” had migraine

“Brain attack”Trigger – Dorsal ponsProdrome - HypothalmusAura – Cerebral cortexPeripheral sensitisation – Cranial vasculatureCentral sensitisation – ThalamusNausea/vomiting- Area Postrema Autonomic symptoms – Parasympathetic

systemNeck pain – Sensitisation of C2/C3

Why me?Blame your parentsChemical imbalanceYour brain is differentSymptoms between attacks

Chronic headache2-3% of population have headache on

more days than don’tHalf of above have medication overuse2%/year migraine transforms to chronicMost preceded by episodic headacheCo-mordidities anxiety,depression,obesityDifficult to manage

Causes chronic daily headachePrimary headachesChronic tension type headacheChronic migraineChronic cluster headacheMedication overuse headacheNew daily persistent headacheHemicrania continua

History in chronic headachePattern

Low grade all time?Low grade with exacerbations?Short lasting frequent?

Stable or progressive?8 questionsMedication including OTC?Caffeine consumption?Exclude red flags

What not to missIdiopathic intracranial hypertensionLow pressure headache Giant cell arteritisOther secondary headache

REMEMBERHigh pressure headache WORSE on lying flatLow pressure headache BETTER lying flat

Don’t forgetBPPalpate temporal arteries >50ESR/CRP >50DOCUMENT WHAT YOU DO

Acute medication in migraineParacetamolAspirin 900mgNaproxen 500mgDomperidone if nauseaConsider suppositoriesAlmotriptan 12.5mg Other triptan if Almotriptan ineffectiveZolmitriptan nasal spraySumatriptan injection

ProphylaxisPropranolol 80-240mgAmitriptyline 10-100mgPizotifen if youngTopiramate or EpilimTake 6-8 weeks to kick inSee regularly

Don'ts in migraine treatmentOver the counterOpioidsCaffeineMigraleaveAnalgesia more than 2-3 days per

week

Sir William Osler again“One of the first duties of the

physicians to educate the masses not to take medicines”

Medication overuse headacheHeadache >15 day per monthIntake of following for 3months

Simple analgesia >15 days per monthOr Opioids/triptans/combination analgesia >10

days per month

Headache resolves or returns to previous pattern within 2months of discontinuation of analgesia

What do you do when you get a headache?Stay still =MigrainePace up and down = ClusterTake tablet = Medication overuse

Management of chronic headacheExclude red flagsEstablish phenotypeLifestyle measuresAvoid caffeine Stop analgesia(Occasional Naproxen)Start prophylaxis according to phenotypeRegular follow up

“ The very first step towards success in any occupation is to become interested in it”

Sir William Osler (1849-1919)Canadian Physician