NuTH Neurology GP Event 19/04/2018

1. A guide to headache in
general practice
Adam Cassidy
Consultant Neurologist
Sunderland Royal Hospital

2. Headache
• Aim
• To increase clinical confidence when seeing patients with
headache
• Outcomes
• Identify those patients who need urgent investigation and
management
• Describe the community management of common
headache syndromes
• Not to cover everything you might need to know about
headache

3. Case 1
• 40 year old woman
• Severe headaches once a week
• Often has to go and lie down
• Last until the next day
• Bilateral
• Constant
• Nauseated
• No photophobia or phonophobia
• Worse with routine activity

4. Migraine Diagnostic Criteria
• At least 5 attacks
• Last between 3 and 72 hours
• Any two of
• Moderate or severe
• Unilateral
• Throbbing
• Worse with routine physical activity
• At least one of
• Nausea or vomiting
• Photophobia and phonophobia
A bilateral, non-throbbing moderately severe headache with no
photophobia can still pass these strict criteria

5. Lifestyle measures
• If the patient hasn’t identified dietary triggers,
they probably aren’t relevant
• Keep well hydrated
• Avoid prolonged hunger
• Regular sleep habits
• Address anxiety and depression

6. Acute drug treatment
• Triptan
• Sumatriptan first line in severe migraine
• Take as soon as pain starts
• If ineffective after 3 doses, systematically work through others
• NSAIDs
• Naproxen 500mg
• Consider anti-emetic
• Metoclopramide 10mg

7. Migraine Prophylaxis
• Usually for severe migraines occurring at
least weekly
• Keep a headache diary
• Cannot determine efficacy until on full dose
for at least 8 weeks
• If helpful, stay on for at least 6 months

8. Prophylactic agents
• Propranolol LA 80mg OD (160mg)
• Well tolerated, but not in those who
exercise
• Common SEs of fatigue and cold
peripheries

9. Topiramate
• 25mg nocte, increasing by 25mg every week up
to 50mg BD
• Common SEs include temporary paraesthesia of
hands and feet and weight loss
• Rare side effects include depression, glaucoma
and kidney stones
• Teratogenic
• No interaction with OCP at dose of 50mg BD

10. Other prophylactics
• Amitriptyline
• Pregabalin
• Valproate
• Pizotifen

11. Case 2
• 60 year old man
• Constant bilateral headache
• Mild to moderate
• All day every day
• No other neurological symptoms

12. Digging deeper...
• “Does the headache ever get really bad?”
• “Do you ever have to lie down?”
• “When the pain is at it’s worst:”
• “Does it feel throbbing, pulsing or stabbing?”
• “Do you ever feel sick or off your food?”
• “Could you tolerate sitting in a bright room like this one
or would you feel better turning the lights down?”
• “Is the pain worse if you move your head or rush around?
Do you feel that you need to keep your head still?”

13. Case 2
• 60 year old man
• Constant bilateral headache
• Mild to moderate
• All day every day
• 4 times a week gets migrainous
exacerbation
• Takes daily paracetamol for mild headaches
• Takes codeine for severe headaches
• No other neurological symptoms

14. Chronic migraine
• For at least 3 months, must have:
• 15+ headache days per month
• 8+ of which must meet earlier definition
of migraine

15. “Chronification”
• Analgesic overuse
• Anxiety and depression / life events
• Minor head injury
• Simple infective illnesses

16. Medication overuse headache
• Opiates and triptans worst culprits
• Limit to no more than 2 doses per week
• On withdrawal, severe headaches for usually no more than two
weeks
• 1/3 get a lot better, 1/3 get a bit better and 1/3 stay the same
• Simple analgesics also implicated
• Avoid all analgesics for background featureless headaches

17. Tension-type Headache
• Renamed “Tension-type” as the cranio-
cervical muscles are not “tense”
• If it exists at all, is very rare
• Vast majority of all chronic daily headaches
likely have a migrainous biology
• As migraines become more frequent they
become less “migrainous”

18. Management
• Patient education and reassurance
• Try to avoid brain imaging
• Life style issues
• Seek and treat anxiety and depression
• Stop all opiates abruptly if possible
• Limit triptans to 2 doses per week
• Prophylaxis with topiramate or amitriptyline

19. Case 3
• 40 year old man
• Severe headache every morning for a month
• “Like a red hot poker in my eye”
• Right eye bloodshot and tearing
• Right nostril blocked
• Restless and agitated
• Lasts an hour

20. Cluster headache
• Only ever unilateral
• Often centred around the eye
• Autonomic features (like some migraines)
• Often regular timings during a cluster
• Relatively brief
• Patients pace around and don’t go to bed

21. Cluster Headache: Management
• Subcutaneous sumatriptan
• Portable high flow oxygen
• Short course of oral steroids
• Prophylaxis with verapamil
• If you think your patient has cluster
headaches, don’t allow them to go
untreated for 3 months!

22. Case 4
• 40 year old man
• 3 weeks ago had severe headache during sex
• At ejaculation felt like being hit over the head with a
cricket bat
• Worst headache ever and reached maximal intensity
immediately
• Pain free within 2 hours
• Had intercourse twice since with identical headaches

23. Benign Coital Headache
• If presents with only one episode, needs admission to
assess for SAH
• After 3 episodes (and probably 2) one can make a safe
diagnosis of benign coital headache
• No investigations required
• Will resolve spontaneously after weeks or months
• Treat with:
• Regular beta blockade
• PRN indomethacin 30-60 mins beforehand (25-100mg)

24. Case 5
• 30 year old man
• Severe bilateral, pulsing headache within
minutes of exertion
• Lasts 30-40 mins and resolves
• Otherwise featurless with no assd
symptoms
• Similar, though less severe headache, when
coughing
• Neurological examination normal

25. Primary exertional headache /
Primary cough headache
• Two related headache disorders which also
overlap with coital headache
• Self limiting over weeks or months
• Similar treatment, with indomethacin or
propranolol
• But...

26. Chiari 1 Malformations
• Need to be excluded in
all cases of true
exertional or cough
headache
• Remember that all
headaches are
exacerbated by
exertion and coughing
• Up to 5% of the
population have an
asymptomatic chiari
malformation

27. Chiari 1 Malformations
• Need to be excluded in
all cases of true
exertional or cough
headache
• Remember that all
headaches are
exacerbated by
exertion and coughing
• Up to 5% of the
population have an
asymptomatic chiari
malformation

28. NICE Referral Criteria

29. When should I be worried?
• In those over the age of 50 with a raised CRP
• In those presenting with a true thunderclap headache
• In those with papilloedema, seizures, fever or focal neurological
signs
• Exertional / cough headaches (though they’re almost all benign)
• And that’s pretty much it!

30. •BRAIN TUMOURS
VIRTUALLY NEVER
CAUSE ISOLATED
HEADACHE!!!

31. When not to get too worried
• Headache worse in the morning
• Headache briefly worsened by straining
• Associated dizziness and vertigo with a
normal tandem gait and no other signs
• Poor memory and concentration in
somebody who attends alone and is
articulate

32. Key points
• It’s almost always migraine!
• True tension-type headache is surprisingly rare
• Avoid causing a medication overuse headache
• Ensure timely triptan use
• Be patient with the prophylactic drugs
• Be aware of the damage caused by incidentalomas
• Cluster headache requires urgent treatment and / or discussion
• A serious cause for headache is very rare, but don’t forget to
check the CRP and the fundi

33. Further Reading