9 September 2016

1. Neurology for
GPs
Dr Naomi Warren
RVI
9th September 2016
naomi.warren@nuth.nhs.uk
naomiwarren@nhs.net

2. Contents
• GP liaison role
• Headaches
o Migraine
o Tension
o Medication Overuse Headache
o Cluster
o Trigeminal Neuralgia

3. GP liaison
• Education
o Feb + May 2016
• Communication/referrals
o A+G
o Routine clinics
o Rapid access clinics
• Pathways
o Headache
o Bells Palsy
o Tremor/PD (next)
naomi.warren@nuth.nhs.uk
naomiwarren@nhs.net

4. Headache
• Common
• 4.4% consults in 10 care
• 30% neuro OPD
• Primary v Secondary
• Sinister headache in 0.1% 10 care
• Est migraine £2 billion/yr to UK
• 100,000 people off work/school due to migraine
each day

5. NICE 2012
• Important to make a +ve
diagnosis

6. History
• Age
• Character/distribution/triggers
• Pattern of headache over time
• Previous headache
• Associated features
• What do they do if bad?
• Any neuro symptoms?
• Medication – inc OTC
• FH

7. Examination (2-3 mins)
• Fundi
• Fields and eye mvmts
• Pyramidal Drift?
• BP
• Quick limb inc reflexes
• Neck mvmts?
• If over 50 think about temporal art palpation

8. Warning Features
 Thunderclap
 Atypical aura
 New onset if > 50yrs
 Progressive, severe
 Cognitive/personality
 Fever
 Symptoms raised ICP
 Drowsy, postural, vomiting
 Hx cancer/HIV
 Progressive neuro deficit
 Papilloedema

9. Case 1
 38 yr old woman
 Headaches 4 years
 Occ, then increasing freq
 3-4 days per week severe, daily ache
 Can wake with h/ache
 Worse if bends over
 Some nausea
 No visual symptoms
 Taking paracet and ibuprofen most days
 Codeine when severe
 Nil on exam

10. • Any photophobia? mild
• What does she do when severe? Lies down
• How long do severe episodes last? Few hours
• Any stresses? no
• Hormones? no
• FH? Mother migraine
• How often codeine? 3-4 days per week
• Diagnosis – migraine +/- MOH
• No tests needed except BP
More History:

11. NICE 2012
• Do not scan primary
headaches for reassurance

12. Migraine
• Life time prev 10% men 22% women
• Characteristically
o Unilat (40% bilat)
o Throbbing
o Build up over mins/hrs
o Moderate – disabling
o Worse with activity
o Nausea*/vomit
o Photo*/phonophobia * = most sens/specific

13. Auras
• 15-30% migraines
• Usually “positive”
• Visual
• Tingling
• Occ negative
• Numbness
• Dysphasia
• 5 – 60 mins
• Can get without headache
• DD TIA – short, sudden,
negative

14. Migraine - misdiagnoses
 50% misdiagnosed
 4-72 hrs – can be longer
 75% neck pain
 <33% vomiting
 Often coexist
 Chronic - 15 days/month over 3/12 – features of
tension/MOH

15. Management
• Identify triggers
o Stress/sleep dep/diet
• Massage/acupuncture etc
• Withdraw any overused meds
• Headache Diary

16. Management
Acute:
 ASA 900mg
 NSAIDs – ibuprofen (dicofenac pr)
 +/-Antiemetics
 Domperidone/metoclop best
 Occ codeine? *caution
 Combination asa + caffeine + para

17. Triptans
 For use at onset headache
 Effective in 50%
 Delivery methods
 Oral – all – sumatriptan cheapest
 S/L – riza + zolmitriptan
 S/C or nasal - sumatriptan
 If no response try alternative
 Combination with ASA/NSAID
 C/I IHD or severe hypertension
 Caution with hemiplegic migraine?

18. Prophylaxis – general
principles
• Given if affecting QOL
• Titrated slowly
• Trial 6-8 weeks
• If effective consider withdrawal after
6-12/12

19. Prophylaxis
• Propranolol LA 80mg - 240mg
o Caution asthma, bradycardia, PVD
• Topiramate 25mg – 50mg bd
o Caution kidney stones/depression/teratogenicity?
• Amitriptyline 10mg – 75mg
o Good if chronic/mixed
• Valproate 800-1200mg/day
o Caution young women
• Gabapentin up to 2400mg/day
• Pizotifen minimal benefit

20. Alternatives:
• Atenolol/metoprolol
• Nortripyline
• Venlafaxine 75-150mg
• Candesartan 8-32mg
• Methysergide – close supervision
• PFO – no benefit
• Bo tox
• recent license chronic
migraine
• >3 prior Tx
• No MOH

21. Women + migraine
 Pregnancy
 Paracetamol
 ASA 300mg/ibu 400mg in 1st/2nd trimester (NICE)
 COC
 Migraine + aura + COCP RR 9 stroke
 >35yrs no aura also increased risk
 Menstrual migraine
 2/7 prior:
 Mefanamic acid/asa/parac/caffeine/triptan (fovatriptan od, naratriptan bd)

22. Who to refer?
• Unsure of diagnosis
• Atypical migraine
o Motor weakness
o Diplopia
o Poor balance
• If adequate trial propranolol/amitrip/topiramate ineffective
• Patient reassurance

23. Case 2
• 25yr old man
• 6 month headache
• Generalised, tight
• Most days
• Neuro examination normal
• What further history?

24. History
• Does he wake up with it? no
• Daily variation? comes on through day
• How severe? Can carry on activities
• Associated n, v, photo/phono? no
• Analgesia? Occ parac
• Relieving/agg factors? No
• Diagnosis – Tension type headache

25. Tension Headache
• 50% population
• Episodic/chronic (>15 days/month)
• Mild/mod
• Featureless
• No nausea
• Occ scalp tender/photo/phono
• Often overlap/misdiagnosis with migraine

26. Management
• Massage/acupuncture/lifestyle
• Acute
o ASA or paracetamol
o NSAIDs
• Prophylaxis
o Amitrip/nortrip up to 75mg
o ?underlying depression
o Venlafaxine/mirtazepine

27. Medication overuse
Headache
• Usually in migraineurs/10 headache
• If h/ache >15 days/month began/worsened whilst taking
analgesia
• At risk if:
• Triptans/opiods >10 days/month
• ASA/para/NSAIDs >15 days /month
• For >3/12

28. Management MOH
• Abrupt withdrawal >1/12
• Opioids – gradual
• Treat any dependence
• Consider prophylaxis if fails
o Topiramate of propranolol
• Warn H/ache will worsen initially
• Review at 4-8/52

29. Case 3
• 50 yr old man
• 3/52 headache
• R sided severe for 30 mins
• Background ache
• No visual symptoms
• Notices droopy R eyelid when severe
• What other questions?

30. History case 3
• Always right side
• Tearing – yes
• Excruciating
• Doesn’t know what to do – wants to bang head off
wall
• 5 per day – mostly through night
• No prev headache
• No medication helps
• Examination normal
Diagnosis?

31. Cluster Headache
Trigeminal autonomic cephalgia
Prev 1/1000
Male middle age
Strictly unilat
Often night
Aggitated
Tearing
Horner’s
<8/day

32. Cluster headache
management
o MRI
o Treatment:
• Acute – triptan (s/l, s/c), O2, steroids
• Prophylaxis – verapamil
o Refer all

33. 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
migraine preventatives. Is it
chronic daily headache
(>15/7 per month)?
Use headache diary
Migraine or 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 contraindicated in migraine with aura
• Ensure not overusing analgesics or 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: Beneficial lifestyle modifiers for 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 following for 3 months at the highest tolerated target dose before judging efficacy:-
a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;
b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:
teratogenic and potential interaction with oral contraceptives. Increasing in 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 standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred:
riboflavin 400mg - 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 referral to rheumatology as
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 Neurology
emergency clinic
(fax 0191 2824370)
Yes
Yes
No

34. 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
anti-emetic, 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
•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 may 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)

35. Other headaches..
 Temporal arteritis >50yrs
 Trigeminal neuralgia
 Cervicogenic
 TMJ dysfunction
 Sinuses
 Primary low pressure
 postural

37. Trigeminal Neuralgia
• Usually V2 + V3
• Sensitive, excruciating
• First line treatment: Carbamazepine
• Alternatives: gbp, pregabalin, oxcarbazepine,
amitriptyline, baclofen.
• Who to refer?
o Uncertain diagnosis/atypical
o If do not respond to cbz
o young
• Investigation – if needed
o MRI – vasc loop, demyelination, compression

38. Conclusions
• Headaches are very common
• Migraine underdiagnosed
• Most are benign but rare serious cause
• Most can be managed in primary care
• Refer in/advice and guidance if
o Unsure of diagnosis
o Atypical features
o Inadequate response to treatment
• www.newcastle-hospitals.org.uk/neurogps