Headache in top 10 of who disability index. Headache in top 10 of who disability index


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Headache in top 10 of WHO disability index.

  • Headache in top 10 of WHO disability index.







Need glasses

  • Need glasses

  • Blood pressure

  • Brain tumour





85% migraine

  • 85% migraine

  • 10% Tension type headache

  • 5% secondary headache

  • <1% other types of headache





Consultation rates are low. 50% of migraine sufferers have never seen a doctor

  • Consultation rates are low. 50% of migraine sufferers have never seen a doctor

  • 10% are under continuing care

  • One third of headaches will be incorrectly diagnosed.



Less than 20% will receive Triptan Walling 2006

  • Less than 20% will receive Triptan Walling 2006

  • 10% of those who would benefit from prevention receive it Rahimtoola 2005



9% GP presentations are referred to secondary care (25% children)

  • 9% GP presentations are referred to secondary care (25% children)

  • (Loughey)

  • 20 - 30% of neurology referrals are for headache (Hopkins)





Migraine 55%

  • Migraine 55%

  • TTH 25%

  • Cluster 7%

  • Trauma 1.6%

  • Trig Neuralgia 1.6%

  • Sinusitis 1.6%

  • Vascular disorders 1.2%

  • Low Pressure 1.2%

  • Meningitis 0.35%

  • Tumour 0.17%

  • Other Misc < 5%



35 year old male

  • 35 year old male

  • Three week history

  • Sharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively.

  • One question?

  • Two examinations?

  • Would you investigate?





Tension – raised intracranial pressure

  • Tension – raised intracranial pressure

  • Compression – tumour

  • Inflammation - migraine,meningitis,blood



Arteritis

  • Arteritis

  • Neuralgia

  • Muscle tension

  • Facial structures



Migraine

  • Migraine

  • Tension type

  • Autonomic cephalalgias (cluster)







35 year old male

  • 35 year old male

  • Three week history

  • Sharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively.

  • One question?

  • Two examinations?

  • Would you investigate?



Fundoscopy

  • Fundoscopy

  • BP

  • ‎Giles Elrington neurological examination



35 year old male

  • 35 year old male

  • Three week history

  • Sharp, severe pain bilaterally and posteriorly lasting 10 seconds repetitively.

  • One question?

  • Two examinations?

  • Would you investigate?



  • EXCLUDE A SECONDARY HEADACHE

  • Do something now

  • Do something soon

  • DIAGNOSE A PRIMARY HEADACHE

  • Exclude medication overuse and manage the primary headache





Sub Arachnoid - thunderclap headache

  • Sub Arachnoid - thunderclap headache





lasts 1-3 mths.

  • lasts 1-3 mths.

  • Primary or secondary

  • Normal CT, LP. Needs CT angio.

  • Can get complications













Injectable sumatriptan



55 year old male.

  • 55 year old male.

  • New headache. L temporal. Fluctuating in intensity. Featureless. Examination normal.

  • What would you do?







Pre orgasmic or orgasmic (10% SAH)

  • Pre orgasmic or orgasmic (10% SAH)

  • Primary or secondary (vascular, tumour, Arnold Chiari)

  • Low threshold for investigation

  • Treatment

  • Technique

  • B blocker

  • Indometacin

  • Avoid recreational drugs



Non specific headache

  • Non specific headache

  • Tinnitus

  • Two examinations

  • What is most likely diagnosis?









  • High impact ++

  • Peri-orbital clusters 15mins - 3 hours

  • Cluster attacks and periods

  • Unilateral autonomic features

  • Acute or chronic



Injectable Sumatriptan

  • Injectable Sumatriptan

  • Nasal Zolmitriptan

  • Short term steroids

  • Oxygen 100%

  • Verapamil



45 year old female

  • 45 year old female

  • Dull continuous bilateral occipital pain

  • Featureless

  • Worried as friend had brain tumour and wants a scan

  • Three questions?

  • Do you investigate?



Have you ever had migraine?

  • Have you ever had migraine?

  • Do you have problems with your neck?

  • What pain killers are you taking?

  • To scan or not to scan?





Meningioma 20% - 10 yr survival 80%

  • Meningioma 20% - 10 yr survival 80%

  • Glioma 70% - 5yr survival 20%

  • Misc. 10% - Variable



Headache prevalence with tumour 70%+

  • Headache prevalence with tumour 70%+

  • Headache at presentation 50%

  • Headache alone at presentation 10%

  • (Iverson 1987)







93% normal (25% variations of norm)

  • 93% normal (25% variations of norm)

  • 6.7% abnormalities

  • 56 cysts; 13 vascular abnormalities;4 adenomas; 4 tumours



Limited poor quality evidence base

  • Limited poor quality evidence base

  • Expert opinion

  • Medico-legal case law

  • Patient-doctor characteristics and approach to uncertainty

  • Organisational factors



Abnormal neurological symptoms or signs

  • Abnormal neurological symptoms or signs

  • New seizure

  • History of cancer elsewhere



  • Aggregated by Valsalva manoeuvre

  • Headache with significant change in character

  • Awakes from sleep

  • New headache over 50 years

  • Memory loss

  • Personality change







NHS plan calls for GPSIs to provide local, efficient care

  • NHS plan calls for GPSIs to provide local, efficient care

  • Controversy over concept from primary care

  • Limited evidence base

  • Substitution, complementation, meeting unmet need



GPs first line management

  • GPs first line management

  • GPSI support

  • Tertiary headache centres



Jane is a 28 yr old

  • Jane is a 28 yr old

  • Presents with a visual disturbance lasting 30 minutes. No other symptoms

  • What are the key questions?

  • What is the differential diagnosis





Jane develops a pattern of visual disturbance followed by headache

  • Jane develops a pattern of visual disturbance followed by headache

  • What features would confirm a diagnosis of migraine?

  • How would you manage the acute attack?



Prodrome 60%

  • Prodrome 60%

  • Aura 30 %

  • Headache (30% bilateral)

  • Postdrome



At least 5 attacks

  • At least 5 attacks

  • 4-72 hours (1-72 hours)

  • Two of : unilateral, pulsating, moderate or severe pain, aggregation by physical activity. (bilateral)

  • At least one of: nausea/vomiting, photophobia, phonophobia. (Can be inferred)

  • Not attributed to another disorder.



Recurrent headache that bothers

  • Recurrent headache that bothers

  • Nausea with headache

  • Light bothers





Paracetamol, Aspirin, Domperidone.

  • Paracetamol, Aspirin, Domperidone.

  • Triptan







Treat early

  • Treat early

  • Failure not class effect

  • Not in CVD

  • SSRIs

  • Over 65 years



Jane’s headaches become more frequent. When would you instigate prevention?

  • Jane’s headaches become more frequent. When would you instigate prevention?

  • What is your first choice?



When to instigate?

  • When to instigate?

  • What to use?

  • How long for to assess an effect?

  • What rate dose increase?

  • How long on preventative medication?







Jane has come for contraceptive advice.

  • Jane has come for contraceptive advice.

  • What options does she have?



Fit women - 5/100,000 women years

  • Fit women - 5/100,000 women years

  • Without aura - 15/100,000 women years

  • With aura - 30/100,000 women years

  • Avoid if other risk factors Eg smoking

  • ?POP - probably safe



After a few years, the migraines have settled to monthly and associated with menstruation only. She is fed up with taking regular prevention.

  • After a few years, the migraines have settled to monthly and associated with menstruation only. She is fed up with taking regular prevention.

  • How will you manage this?



Menstrual (pure - 7%, and other times 35%)

  • Menstrual (pure - 7%, and other times 35%)

  • Peri-menopausal



Tricycle OC

  • Tricycle OC

  • Regular NSAI

  • 100 mcg oestrogen patch

  • Regular long acting Triptan



Too much oestrogen too quickly - worse

  • Too much oestrogen too quickly - worse

  • 25 mcg Evoral patch in quarters

  • Avoid oral oestrogen

  • Reassure will get better



Jane brings in her 13 year old son who is getting trouble with headache. In view of the family history you suspect migraine.

  • Jane brings in her 13 year old son who is getting trouble with headache. In view of the family history you suspect migraine.

  • How do features in children differ from adults?

  • Would you image?

  • What treatment would you instigate?







Headache most frequent neurological problem in children and commonest manifestation of pain

  • Headache most frequent neurological problem in children and commonest manifestation of pain

  • 50% Childhood migraine becomes chronic and continues into adulthood

  • <10% will see their GP



10.6% migraine prevalence (3.4% age 5)

  • 10.6% migraine prevalence (3.4% age 5)

  • 10% -24% tension type prevalence

  • 0.01% cluster prevalence

  • Invariably mixed or not well defined



Don’t realise its migraine

  • Don’t realise its migraine

  • Only a headache

  • Parents don’t want to reinforce illness behaviour

  • Parents pattern their health seeking behaviour



  • GPs made diagnosis in 20%

  • 25% referred to secondary care

  • 3 in 10,000 tumour

  • No tumours if migraine diagnosed





Unable to articulate symptoms of raised intracranial pressure

  • Unable to articulate symptoms of raised intracranial pressure

  • Problem may be suggested by their behaviour in ways that may be relatively subtle



Pain is shorter acting

  • Pain is shorter acting

  • More likely to be bilateral

  • Often “mixed”

  • Associated with other systemic presentations



40% headache (<10% headache alone)

  • 40% headache (<10% headache alone)

  • 28% nausea and vomiting

  • 22% motor abnormalities

  • 17% visual abnormalities

  • 17% cranial nerve abnormalities

  • 10% seizures

  • 3% behavioural change

  • Wilme 2010



Abnormal neurological sign

  • Abnormal neurological sign

  • Confusion or disorientation

  • Visual abnormalities

  • Abnormal head position (double vision or neck pain)

  • Cerebella dysfunction

  • Persistent headache for 4 or more weeks at presentation that awake from sleep or occur on waking

  • Persistent headache at any time in a child younger than 4 years

  • Persistent headache for 2 or more weeks with vomiting



Headache with behavioural change

  • Headache with behavioural change

  • Headache with deterioration in school work

  • Headache with growth arrest or abnormal puberty

  • A persistent unilateral or occipital headache

  • A persistent headache in a child with a personal or family history of childhood tumour

  • Recent change in headache characteristics in a previous diagnosed primary headache



Avoidence of triggers

  • Avoidence of triggers

  • Analgesia +-Domperidone

  • Sumatriptan nasal

  • Pizotifen

  • Propranolol

  • Amitrip

  • Topiramate





Migraine - lie down

  • Migraine - lie down

  • Tension Type Headache - keep going

  • Cluster Headache - bang head against wall











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