Headache Feb 2016

1. Headache Dr Gina Kennedy Consultant in Neurology Sunderland Royal Hospital

2. 29 million headache-suffering days in UK annually • 30% Neurology OPD • 100,000 people off school/work/day • Huge socioeconomic burden

3. Aims: Today we need to … • Review primary headache diagnosis(ICHD II) • Practical management (NICE) • Headaches not to miss: when to refer/ to scan or not to scan • Leave without a headache

4. Adult with Headache Emergency symptoms?1 Refer to appropriate on-call hospital team Red flags?3 Use Advice & Guidance Service or refer general neurology Can you make a diagnosis of primary headache disorder? Prescribe acute treatment (< 10 days/month)4 Refer to headache clinic Inadequate response to migrainepreventatives. Is it chronic daily headache (>15/7 per month)? Use headache diary Migraineor tension headache4 ? Giant cell arteritis?2 • Encourage patient understanding: direct to www.migrainetrust.org; supply with patient headache leaflets and diaries • If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicatedin migraine with aura • Ensure not overusing analgesicsor triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset. Migraine prophylaxis: Beneficiallifestyle modifiersfor headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger avoidance, stress management techniques, normalise BMI, daily aerobic exercise) Consider prevention if >4/7 per month: try the followingfor 3 months at the highest toleratedtarget dose before judging efficacy:- a) Propranolol MR 80mg o.d. increasing graduallyif tolerated to a maximum of 240mg a day; b) If ineffectiveor contraindicated:Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE: teratogenic and potential interactionwith oral contraceptives. Increasingin 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression. c) Other options [unlicensed, but standardpractice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin400mg - patients source or acupuncture Tension Type Headaches:Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse. Cluster headache?5 Try acute treatments5 Check ESR and CRP Prednisolone 60mg o.d. immediately Consider urgent referralto rheumatologyas appropriate2 (Need temporal artery biopsy within 2 weeks of starting prednisolone) Yes Yes No No No No Yes Northern East Headache Management Guideline November 2015 Refer urgently to Neurology Yes Yes Consider CT brain pre-referral

5. 1) 3) Migraine (don’t need a full house!) • Throbbing pain lasting hours - 3 days • Sensitivity to stimuli: light and sound, sometimes smells • Nausea • Aggravated by physical activity (prefers to lie/sit still) Aura (if present):- • evolves slowly (in contrast to TIA/stroke) • lasts minutes - 60min ‘Chronic Migraine’ ≥15 headache days/month of which ≥8 are migraine Acute treatments: Aspirin disp. 900mg or NSAID, taken with prochlorperazine A triptan, but no more than 9 days per month (best <6/month) Don’t use opiates as they tend to lead to increase nausea and lead to an overuse headache Poor absorption common in a headache attack – therefore better efficacy with antiemetic, or non-oral (e.g. diclofenac supp, s/c or nasal triptan) Tension Type Headache Band-like ache Mostly featureless Can have mild photo OR phonophobia but NO nausea Many believe this is simply a milder form of migraine (i.e. same biology and thus similar treatments can be effective) Cluster Headache (Mostly men) Most severe pain ever lasting 30-120 minutes Unilateral, side-locked Agitation, pacing (cf migraineurs prefer to keep still) Unilateral Cranial Autonomic features:- tearing, red conjunctiva, ptosis, miosis, nasal stuffiness Acute treatments: Sumatriptan injection 6mg s.c. (Contraind.: IHD and stroke) Hi-flow oxygen through a non-rebreathe bag and mask (10-12litres/min) Prednisolone 60mg o.d. for 1 week can abort a bout of attacks 2) Analgesic/Triptan Overuse Headache Often mixture migraine and background headache Analgesic intake ≥15 days/month (opiates/triptans ≥10 days) for ≥3 consecutive months Treatment: stop analgesic and triptan for 2 months and follow up Red Flags • Headache rapidly increasing in severity and frequency despite appropriate treatment. • Undifferentiated headache (not migraine / tension headache) or new persistent daily headache of recent origin and present for >8 weeks with focal neurological signs or high clinical suspicion of underlying structural cause. • Recurrent headaches triggered by exertion • New onset headache in:- >50 years old (consider giant cell arteritis) Patients with focal neurological signs or change in personality Immunosuppressed / HIV 4) Emergency Symptoms/signs Thunderclap onset (i.e. max intensity in <5 mins) Accelerated/Malignant hypertension Acute onset with papilloedema Acute onset with focal neurological signs Head trauma with raised ICP headache Photophobia + nuchal rigidity + fever +/-rash Reduced consciousness Acute red eye: ?acute angle closure glaucoma New onset headache in: • 3rd trimester pregnancy/early postpartum • Significant head injury (esp. elderly/ alcoholics / on anticoagulants) Giant Cell arteritis (Incidence 2/10,000/ year) • Think about it: New headache in >50 year old • Other headaches may briefly respond to high dose steroids, so do not use response as the sole diagnostic factor. • ESR can be normal in 10% (check CRP as well) • Symptoms of classical GCA can include: jaw/tongue claudication, visual disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudication Urgent referral: rheumatology if GCA diagnosis suspected, ophthalmology or TIA clinic if amaurosis fugax / visual loss / diplopia (not migrainous auras!). Patient in GP setting: Who to scan ? Basically, no-one who does not need referring in needs a scan. However, if a scan is being done for reassurance, a CT head scan will suffice. 5) 6)

7. Headache Clinic • History: – PMH : ‘headachy person?’, lifestyle changes – short or long lasting headache? 4 hours – description of severe attack and frequency – associated symptoms – functionally limiting? – number of HEADACHE-FREE days/month • Examination: – Fundoscopy, visual fields, palpation of temporal arteries, TMJ, neck muscles, cervical spine • Headache Impact Test Score >60 severe • Use of diaries to record headaches, associated symptoms and medication use- identify patterns

8. Primary Headache Headache with any of: Nausea/photo/ phonophobia Throbbing/Unilateral/ Movement Aura? Visual/sensory/ speech Migraine with aura Migraine without aura Menstrual Migraine Medication over use excluded?* Tension Type Headache Medication overuse headache <15 days/month: Episodic >15 days/month: Chronic Yes Yes Yes No No No * Use of triptans/opioids > 10 days/month, paracetamol/NSAIDS>15 days/month

9. Case 1 • 34 year old female 4 year history of mainly right sided headache approximately twice a month which radiate over rest of head lasting 2-3 days • No nausea but ‘off food’ with no photophobia, phonophobia, worse with playing netball • Typically feels hungry and lethargic with recurrent yawning in days leading up to headache A.Migraine without aura B. Migraine with aura C. Chronic migraine D. Tension-type H/A E. Trigeminal autonomic cephalalgia F. Medication overuse headache G. Other

10. Case 1 • 34 year old female 4 year history of mainly right sided headache approximately twice a month which radiate over rest of head lasting 2-3 days • No nausea but ‘off food’ with no photophobia, phonophobia, worse with playing netball • Typically feels hungry and lethargic with recurrent yawning in days leading up to headache A.Migraine without aura B. Migraine with aura C. Chronic migraine D. Tension-type H/A E. Trigeminal autonomic cephalalgia F. Medication overuse headache G. Other

11. Migraine without Aura

12. Migraine with aura • 20% migraine patients • Focal reversible neurological disturbance • Onset 5-20 minutes, 5-60 minutes duration • At least one of: Visual > sensory > dysphasia • No motor weakness • Refer if atypical (no headache, motor weakness, monocular visual symptoms, altered GCS) • Differential TIA: sudden, negative

13. Migraine: misdiagnosis • 50% misdiagnosed • 4-72 hours: can be longer • 75% neck pain • 1/3 nausea and vomiting • Chronic: headache 15 days/month, only 8/30 days a month with migraine features

14. Migraine: acute treatment • 1. LIFESTYLE – Stress/ sleep/ diet/ caffeine • 2. simple oral analgesia +/- antiemetic – Aspirin 600-900mg/ ibuprofen 400-600mg soluble – Prochlorperazine 3-6mg buccal tablet/ domperidone 10mg – Migraleve/Paramax • 3. Rectal preparations – Diclofenac suppositories 100mg – Domperidone suppositories 30- 60mg • 4. Triptans – Oral sumatriptan – Nasal spray sumatriptan/ zolmitriptan – Sublingual zolmitriptan/ rizatriptan – Subcutaneous sumatriptan • 5. Combination therapy – Sumatriptan + naproxen • 6. Emergency treatment – Sumatriptan 6mg s.c. – Diclofenac 75mg i.m. – Chlorpromazine 25-50mg/ metaclopramide 10mg/ prochlorperazine 12.5mg

15. Migraine Prophylaxix • Affecting QOL: consider anything over 1 x migraine/month • Titrate slowly and complete at least 6-8 weeks • Reach highest tolerable/ effective dose • Review 3-6 monthly

16. Migraine Prophylaxis • Class C: – Candesartan 8-32mg od – Lisinopril • Less: – Gabapentin/ pregabalin – Verapamil • Class A: – Topiramate 25-50mg bd – Sodium valproate 600- 1200mg bd • Class B: – Propanolol 80-240/day – Amitriptyline 30-150mg – Nortiptyline 25-100mg – Atenolol 25-50mg bd – Feverfew – Riboflavin B2 400mg /day

17. Migraine in women • Menstual migraine: Naproxen 250-500mg bd, Frovotriptan 2.5mg-5mg bd, Tricyclic OCP, oestrogen patches (100 micrograms for 3/7) • Pregnancy: Paracetamol, Propanolol, Prochlorperazine, Amitripyline, triptans • CVA risk: migraine without aura (1.83 RR), migraine with aura (2.17 RR)+ COCP + smoker = 9 x CVA risk

18. Chronic migraine • Headache fulfilling diagnostic criteria for migraine without aura • for at least 15 days/month for 3 months • Only 8 of which have migrainous features • In absence of medication overuse

19. Botulinum Toxin • Technology Appraisal TA 260 • Chronic migraine • 3 x failed preventatives • Medication overuse addressed • BoTox discontinued if <30% improvement or <15 days/month (episodic) • PREEMPT study: reduced headache days (8-9/month cf placebo 6/month), well tolerated • 155 units in 31 sites

20. What the patient’s say.. • “I feel like I can be a mother to my children again” • “I don’t feel I am overstating things to say it has changed my life!” • “My family have noticed the benefit, I am spending more time out of my bedroom” • “My wife now wakes up smiling” • “Remarkable” • “I have been able to stop topiramate and start planning a family”

21. Case 2

22. Case 2 • Migraine without aura • Migraine with aura • Chronic migraine • Tension-type H/A • Trigeminal autonomic cephalalgia • Medication overuse H/A • Other

23. Case 2 • Migraine without aura • Migraine with aura • Chronic migraine • Tension-type H/A • Trigeminal autonomic cephalalgia • Medication overuse H/A • Other

24. Medication Overuse Headache • Headache diary! • Triptan, opioid, ergot >10 days month • Paracetamol, aspirin, NSAID >15 days/month

25. Management MOH • Stop overused medication • Consider starting a prophylaxis in patients with migraine (amitriptyline, beta-blocker, valproate) • Naproxen 250-500mg bd for 6/52 • Warning: things get worse before getting better, aim to review regularly, should start to see benefit at 1 month • Review diagnosis at 2 months

26. Medication overuse outcome

27. Case 3 • Migraine without aura • Migraine with aura • Chronic migraine • Tension-type H/A • Trigeminal autonomic cephalalgia • Medication overuse H/A • Other • 42 year old man, 3/12 moderate constant generalised headache with tender areas • No nausea • Not worse with moving, position or Valsalva • Can continue daily activities

28. Case 3 • Migraine without aura • Migraine with aura • Chronic migraine • Tension-type H/A • Trigeminal autonomic cephalalgia • Medication overuse H/A • Other • Bilateral pressing/tightening quality, with or without pericranial tenderness (on manual palpation) • 30 minutes-7days • Not worsened by physical activity • No nausea, occasional mild photophobia/phonophobia • Associated with depression/ anxiety • Temporomandibular joint dysfunction, referred neck pain (cervicogenic)

29. Tension type headache: treatment • Bilateral featureless ‘tight’ constant headache • Acute treatment: NSAIDS, aspirin, paracetamol • Amitriptyline, duloxetine, dosulepin, mirtazepine • Relaxation/massage/heat/exercise • Acupuncture: 10 sessions over 5-8 weeks

30. Case 4: Video

31. 3. Trigeminal Autonomic Cephalalgias • Headache with activation of trigeminal parasympathetic reflex (conjunctival injection and lacrimation, rhinorrhoea, miosis, ptosis (Horner’s), facial sweat, agitation) • Cluster headaches: episodic (15-180 mins up to 8x/day for several weeks) / chronic (> one year with remission periods less than 1 month) • Paroxysmal hemicrania (2-30 mins 40x/day) Indomethacin- sensitive! • SUNCT (short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing) (5 secs-4mins 30x/hour)

32. Cluster Headache • Men, 30’s, smokers • Unilateral excrutiating pain over one eye for 1-3 hours, same time each day, commonly at night (REM sleep as trigger) • Agitated • Bouts for 6-12 weeks, 1-2 X per year • Worse with ETOH • Differential: Hypnic headache (ask about sleep apnoea, nocturnal hypertension)

33. Treatment: Cluster headache • Stop smoking/ETOH • Sumatriptan 6mg subcut./nasal spray • High flow 100% oxygen 10-15L/min • Intranasal lignocaine 2% • 1mg/kg prednisolone for 2/52, reduce by 10mg/day • Verapamil 80mg tds-320mg tds, check ECG at every increment • Methysergide 1-12mg • Lithium 200 bd- 800 bd • Topiramate/gabapentin/melatonin

35. When is it an emergency? • Emergency Symptoms/signs • Thunderclap onset (i.e. max intensity in <5 mins) • Accelerated/Malignant hypertension • Acute onset with papilloedema • Acute onset with focal neurological signs • Head trauma with raised ICP headache • Photophobia + nuchal rigidity + fever +/-rash • Reduced consciousness • Acute red eye: ?acute angle closure glaucoma • New onset headache in: •3rd trimester pregnancy/early postpartum •Significant head injury –(esp. elderly/ alcoholics / on anticoagulants)

38. When is it GCA? • Giant Cell arteritis (Incidence 2/10,000/ year) •Think about it: New headache in >50 year old •Other headaches may briefly respond to high dose steroids, so do not use response as the sole diagnostic factor. •ESR can be normal in 10% (check CRP as well) •Symptoms of classical GCA can include: jaw/tongue claudication, visual disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudication • Urgent referral: rheumatology if GCA diagnosis suspected, ophthalmology or TIA clinic if amaurosis fugax / visual loss / diplopia (not migrainous auras!).

40. When to scan? •Red Flags •Headache rapidly increasing in severity and frequency despite appropriate treatment. •Undifferentiated headache (not migraine / tension headache) or new persistent daily headache of recent origin and present for >8 weeks with focal neurological signs or high clinical suspicion of underlying structural cause. •Recurrent headaches triggered by exertion •New onset headache in:-  >50 years old (consider giant cell arteritis)  Patients with focal neurological signs or change in personality  Immunosuppressed / HIV Patient in GP setting: Who to scan ? Basically, no-one who does not need referring in needs a scan. However, if a scan is being done for reassurance, a CT head scan will suffice.

41. What to refer • High suspicion secondary cause • Complicated headache type for diagnosis • Headache refractory to treatment • BEFORE referral: – Optimise rescue treatment – Review medication overuse – Try prophylactics x 3

42. Summary • Headaches are common • Diagnosis and appropriate treatment/referral of primary headaches • Identify symptoms/signs of serious causes and triage according to pathway • Hopefully now leave without a headache!

43. Useful Information • www.ihs-headache.org • www.bash.org.uk • www.ouchuk.org • www.exeterheadacheclinic.org.uk For patients: • National Migraine Centre: www.nationalmigrainecentre.org.uk • www.migrainetrust.org.uk

45. 1) 3) Migraine (don’t need a full house!) • Throbbing pain lasting hours - 3 days • Sensitivity to stimuli: light and sound, sometimes smells • Nausea • Aggravated by physical activity (prefers to lie/sit still) Aura (if present):- • evolves slowly (in contrast to TIA/stroke) • lasts minutes - 60min ‘Chronic Migraine’ ≥15 headache days/month of which ≥8 are migraine Acute treatments: Aspirin disp. 900mg or NSAID, taken with prochlorperazine A triptan, but no more than 9 days per month (best <6/month) Don’t use opiates as they tend to lead to increase nausea and lead to an overuse headache Poor absorption common in a headache attack – therefore better efficacy with antiemetic, or non-oral (e.g. diclofenac supp, s/c or nasal triptan) Tension Type Headache Band-like ache Mostly featureless Can have mild photo OR phonophobia but NO nausea Many believe this is simply a milder form of migraine (i.e. same biology and thus similar treatments can be effective) Cluster Headache (Mostly men) Most severe pain ever lasting 30-120 minutes Unilateral, side-locked Agitation, pacing (cf migraineurs prefer to keep still) Unilateral Cranial Autonomic features:- tearing, red conjunctiva, ptosis, miosis, nasal stuffiness Acute treatments: Sumatriptan injection 6mg s.c. (Contraind.: IHD and stroke) Hi-flow oxygen through a non-rebreathe bag and mask (10-12litres/min) Prednisolone 60mg o.d. for 1 week can abort a bout of attacks 2) Analgesic/Triptan Overuse Headache Often mixture migraine and background headache Analgesic intake ≥15 days/month (opiates/triptans ≥10 days) for ≥3 consecutive months Treatment: stop analgesic and triptan for 2 months and follow up Red Flags • Headache rapidly increasing in severity and frequency despite appropriate treatment. • Undifferentiated headache (not migraine / tension headache) or new persistent daily headache of recent origin and present for >8 weeks with focal neurological signs or high clinical suspicion of underlying structural cause. • Recurrent headaches triggered by exertion • New onset headache in:- >50 years old (consider giant cell arteritis) Patients with focal neurological signs or change in personality Immunosuppressed / HIV 4) Emergency Symptoms/signs Thunderclap onset (i.e. max intensity in <5 mins) Accelerated/Malignant hypertension Acute onset with papilloedema Acute onset with focal neurological signs Head trauma with raised ICP headache Photophobia + nuchal rigidity + fever +/-rash Reduced consciousness Acute red eye: ?acute angle closure glaucoma New onset headache in: • 3rd trimester pregnancy/early postpartum • Significant head injury (esp. elderly/ alcoholics / on anticoagulants) Giant Cell arteritis (Incidence 2/10,000/ year) • Think about it: New headache in >50 year old • Other headaches may briefly respond to high dose steroids, so do not use response as the sole diagnostic factor. • ESR can be normal in 10% (check CRP as well) • Symptoms of classical GCA can include: jaw/tongue claudication, visual disturbance, temporal artery: prominent, tender, diminished pulse; other cranial nerve palsies, limb claudication Urgent referral: rheumatology if GCA diagnosis suspected, ophthalmology or TIA clinic if amaurosis fugax / visual loss / diplopia (not migrainous auras!). Patient in GP setting: Who to scan ? Basically, no-one who does not need referring in needs a scan. However, if a scan is being done for reassurance, a CT head scan will suffice. 5) 6)

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