HEADACHE Dr Nick Pendleton - PowerPoint Presentation

Slide1

HEADACHE

Dr Nick

Pendleton

September

2015

Slide2

HeadacheTension Type HeadacheCranial Nerve Examination

Migraine

Migraine Treatment

Medication Overuse Headache

Headache Red Flags

Sinusitis Headache

Raised ICP Headache

Acute Severe Headache

Slide3

Small Group WorkTension Type HeadacheCranial Nerve Examination

Migraine

Migraine Treatment

Medication Overuse Headache

Headache Red Flags

Sinusitis Headache

Raised ICP Headache

Acute Severe Headache

Slide4

NICE GUIDELINE CG150

Diagnosis

and Management of

Headaches

in Young People and

Adults

https://www.nice.org.uk/guidance/cg150

Slide5

DIAGNOSTIC CRITERIA FOR TTH

At least 10 episodes fulfilling the criteria B-D:

(

B

) Headache lasting from 30 minutes to 7 days

(

C

) Headache has at least two of the following characteristics:

Bilateral location

Pressing/tightening (non-pulsating) quality

Mild or moderate intensity

Not aggravated by routine physical activity such as walking or climbing stairs

(

D

) Both of the following:

No nausea or vomiting (anorexia may occur)

No more than one episode of photophobia or

phonophobia

(

E

) Not attributable to another disorder

Slide6

Patient with

Tension-Type Headache

indicating location of his headache pain

.

Loder

E , Rizzoli P BMJ 2008;336:88-92

©2008 by British Medical Journal Publishing Group

Slide7

DIAGNOSTIC CRITERIA FOR TTH

Infrequent

episodic tension-type headache

Diagnosed if headaches meeting the above criteria occur <1 day a month (<12 days a year) on average

Frequent

episodic tension-type headache

Diagnosed if headaches occur >1 and <15 days a month (>12 and <180 days a year).

Chronic

tension-type headache

Diagnosed if headaches occur ≥15 days a month (180 or more days a year).

Slide8

RED FLAGS

Onset of new or different headache

Nausea or vomiting

Worst headache ever experienced

Progressive visual or neurological changes

Paralysis

Weakness, ataxia or loss of co-ordination

Drowsiness, confusion, memory impairment or loss of consciousness

Onset of headache after age of 50 years

Slide9

More RED FLAGS

Symptoms/Signs of

Papilloedema

Stiff neck

Onset of headache with exertion, sexual activity or coughing

Systemic illness

Numbness

Asymmetry of

pupillary

response

Sensory loss

Signs of

meningeal

irritation

Slide10

Link to Article about Red Flagshttp://www.gponline.com/red-flag-symptoms-headaches/neurology/headache-migraine/article/1332134

Slide11

Slide12

Slide13

Slide14

MIGRAINE

Slide15

Slide16

Migraine

Repeated attacks of headache lasting 4–72 hours that have these features :

A

: Normal physical examination

B

: No other reasonable cause for the headache

C

: At least two of: Unilateral pain

Throbbing pain, Aggravation of pain by movement, Moderate or severe intensity of pain

D

: At least one of Nausea or Vomiting

Photophobia and

phonophobia

Slide17

MIGRAINE WITH AURA

20–30% experience migraine with aura

Focal neurological phenomena that precede the attack

Appear gradually over 5 to 20 minutes and generally last fewer than 60 minutes

Headache phase usually begins within 60 minutes of the end of the aura phase.

Slide18

AURA

Common aura symptoms include:

Visual disturbances (such as flashing/flickering lights, zigzag lines and even temporary blindness)

Numbness, tingling sensations and slurred speech.

Other aura symptoms include a stiff neck, weakness on one side, partial paralysis, confusion or fainting

Slide19

Migraine, Stroke and the OCPPatients who have Migraine with Aura are at increased risk of ischaemic stroke

Giving these patients an OCP increases this risk significantly

+ Hypertension

+ Smoking

+ age > 35

Slide20

Some figures: In Women under 35:

those who do not have migraine and do not take the pill (i.e. the background risk): 1.3 per 100,000 women per year are at risk of stroke

those who have migraine without aura but don’t take the pill: 4 per 100,000 women per year at risk of stroke

those who have migraine with aura but don’t take the pill: 8 per 100,000 women per year are at risk of stroke

those who don’t have migraine and take the pill: 5 per 100,000 women per year at risk of stroke

those who have migraine with aura and take the pill: 28 per 100,000 women per year at risk of stroke

those who have migraine without aura and take the pill: 14 per 100,000 women per year are a risk of stroke

http://www.migrainetrust.org/factsheet-stroke-and-migraine-10891

Slide21

Treatments for MigraineTriptans, selective 5-HT

1B/1D

receptor agonists –various formulations & types

Ergot derivatives (older treatment, not commonly used)

Antiemetics

&

nsaids

Preventative

: 2/3 will have 50% reduction

Many have significant side effects:

Pizotifen

– weight gain, drowsiness

B- Blockers

– tirednessTricyclics – drowsiness

Anticonvulsants – valproate, topiramate, gapapentin – significant s/e. Botulinum Toxin type A

http://www.nice.org.uk/guidance/ta260

Candesartan

:

http://www.ncbi.nlm.nih.gov/pubmed/24335848

Slide22

Medication

Overuse

Headache

Headache present on at least 15 days per month

Developed or markedly worsened during medication overuse

Headache resolves or reverts to its previous pattern within two months on discontinuation

Regular overuse for three months or more

Slide23

Culprits

Opiates

,

codeine

+/-

paracetamol

10

days

+ per

month

Triptans

or

NSAIDs

15

days

+ per

month

Slide24

Vicious Cycle

Bad

spell

of

headaches

eg

stress

Take

more

painkillers

Body

gets

used

to

medication

Rebound

/

withdrawal

if stop for>1d

Think

this

is

another

usual

headache

Take

more

painkillers

Problem

worsens

Slide25

Blood Pressure and

Headache

Very

High BP

can

cause

Headache

Patients

will

Expect

to have BP

checked

when

presenting

with

Headache

Children

with

Headache

– check BP

3rd

Trimester

Pregnancy

and

Headache

?

Pre

-

eclampsia

Slide26

SINUSITIS HEADACHE

Headache

worse

on

lying

down

Nasal congestion

Nasal

discharge

purulent +/-

blood

Cough

, Fever, Malaise

Tender

at

point of pain

Can

be

unilateral

Treatment

:

http://bjgp.org/content/63/616/611

Slide27

RAISED ICP

New

increasing

headache

Present

on

waking

Increased

by

stooping

or

straining

Changes in mental state

Vomiting

Papilloedema

Causes:

sinister

and

benign

, acute and

chronic

Slide28

Idiopathic Intracranial HypertensionLink to Excellent summary:http://www.patient.co.uk/doctor/idiopathic-intracranial-hypertension-pro

Slide29

SAH

Risk factors similar to stroke

eg

. Smoking, hypertension

Family History in 5-20%

Incidence 6 cases per 100,000 patient yrs

50% fatality, 1/3 remain dependent

Sudden explosive headache

is the cardinal feature.

If related to sexual intercourse ?SAH

CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative

Slide30

SAHA period of unresponsiveness of >1 h

occurs in almost half of patients

Focal signs develop at the same time as the headache or soon afterwards in one third of patients

Classically, the headache from

aneurysmal

rupture develops in seconds, but can be minutes

Slide31

SAHVomiting occurs in 70% of patientsNeck stiffness

is a common sign in SAH of any cause, but

takes hours to develop

and therefore cannot be used to exclude the diagnosis if a patient is seen soon after the sudden-onset headache

If thunderclap headache is the only symptom then 10% only will have SAH, but all need investigation

Slide32

JULIE JONES, 45TELEPHONE TRIAGE CONSULTATION (Dr A)

Headache: started 3 days ago gradual onset worse last night

Started to feel nauseous with it yesterday

Analgesia does help

Global but more at front left

Slight dizziness with nausea no vomiting or visual disturbance of gross neurological symptoms

Suggested comes in for examination but most likely tension type headache

Fictional name and age for illustration

Slide33

JULIE JONES, 45FY2 CONSULTATION IN SURGERY (same day)

3/7 tension like headache, frontal. No photophobia

Vomited 3x overnight

Very stressed with work

Had tension and migraines in the past

Helped when lying down

Not worse bending over

No visual symptoms

Slide34

JULIE JONES, 45Unlikely to be pregnant - partner has had vasectomy. D/W Dr BIbuprofen and

paracetamol

helped marginally

o/e PEARL, no focal tenderness, appears anxious

Discussed stress at work and sleep

hygeine

Advised to return if problem persists or deteriorates

Slide35

JULIE JONES, 45DISCHARGE LETTER Hosp to ITU (1 week later)

Collapsed that evening and had seizure

Intubated

and ventilated

Platelet count 6

Discussed with Haematology

Diagnosis TTP

To Have Plasma Exchange

in Liverpool

Slide36

JULIE JONES, 45Edited Highlights:

Had 3 cardiac arrests, Had plasma exchange

Discharged after 3 weeks

Medication started:

Phenytoin

,

Prednisolone

, Aspirin,

Gliclazide

Haematology follow up, Platelet count recovered

Steroids reduced,

gliclazide

stoppedDriving: notify DVLA. Cannot drive for 6 months

Slide37

LEARNING POINTS?

Slide38

NEXT SESSION

6th

October

–

Eyes

and

Ears

(Dr Helen Wall)