Headache for Optometrists
Dr Paul Davies
Consultant Neurologist

23rd February 2010
The West Wing
Headache for Optometrists
1. Over-view of Headache
2. Common benign headaches
3. Serious headaches
(with some ocular/visua...
Headache in the UK
• Affects nearly everyone occasionally
• Is a problem for around 40% of people
• Is one of the most fre...
Migraine in the UK
• Affects 12-15% of the population
• Affects 3X more women than men
• Most troublesome late teens to ea...
www.i-h-s.org
Primary Headache
“Headache is an integral part of the
syndrome…diagnosis is symptom based.”

Secondary Headache
“A de novo...
Headache Classification
Part 1: The Primary Headaches
Migraine
Tension-type headache
Cluster headache and other TACs
Part ...
Life-time Prevalence of Symptomatic and Nonsymptomatic Headaches in a General Population
Disorder
%
Migraine without aura
...
Differential diagnosis of 906 patients who presented to a
general neurology clinic with headache or facial pain as
the maj...
Primary Headaches
1. Migraine
2. Tension-type headache
3. Cluster headache and other trigeminal autonomic
cephalalgias
4. ...
Migraine
Headache/Pain with Visual/Occular
Symptoms or Signs
Migraine
Migraine without Aura
Migraine with Aura
Migraine Aura (No or...
The burden of migraine
Prevalence
• Migraine is most common during the productive years

20
18
16
14
12
10
8
6
4
2
0

18.3...
The burden of migraine
Disability due to migraine
Normal function
Severe
impairment/
bed rest

9%
53%
38%

Some impairment...
Trigger Factors for Migraine
1. Stress – relaxing
2. Hormonal changes in women
3. Sleep deprivation/lying in
4. Dietary ch...
The Triptans
Imigran (Sumatriptan)
Zomig
Naramig
Maxalt
Relpax
Almogran
Migard
Preventative Drugs
Beta-blockers
eg propranolol, metoprolol, atenolol
Epilim (sodium valproate)
Topamax (topiramate)
Tricy...
Tension-type Headache
Headache/Pain with Visual/Occular
Symptoms or Signs
Tension-type headache
? Due to refractive errors
? Due to squint
? Rel...
Cluster Headache
Horner’s Syndrome in CH
• Appears during
attack
• May persist between
attacks
Cluster Headache
(Migrainous Neuralgia)
• Fairly rare disorder - prevalence 0.1 %
• Male:Female ratio approx. 5:1
• Usuall...
Episodic Cluster Headache
•
•
•
•
•
•

Onset typically 20-30, occasionally older
Bouts of attacks lasting 1week to 4 month...
Headache/Pain with Visual/Occular
Symptoms or Signs
Primary Headache Syndromes
Migraine
Cluster headache and other Trigemi...
Headache/Pain with Visual/Occular
Symptoms or Signs
•
•
•
•
•
•
•

Corneal ulcer
Sceritis/Episcleritis
Glaucoma
?Retinal M...
Serious Causes of Headache
Red Flags in Headache History
•
•
•
•
•

Sudden onset severe headache
New headache in old people
Headache with coughing/st...
Dealing with Headache
1. Is it serious?

The patient’s view

2. If not, what is it due to?

Diagnosis?
Explanation?

3. Ma...
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
Headache  Dr Paul Davies
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Headache Dr Paul Davies

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Headache Dr Paul Davies

  1. 1. Headache for Optometrists Dr Paul Davies Consultant Neurologist 23rd February 2010
  2. 2. The West Wing
  3. 3. Headache for Optometrists 1. Over-view of Headache 2. Common benign headaches 3. Serious headaches (with some ocular/visual emphasis)
  4. 4. Headache in the UK • Affects nearly everyone occasionally • Is a problem for around 40% of people • Is one of the most frequent causes of consultation in both general practice (4% of all adults/year) and neurological clinics (25% of all new referrals) • Represents an immense socio-economic burden
  5. 5. Migraine in the UK • Affects 12-15% of the population • Affects 3X more women than men • Most troublesome late teens to early 50s (working lives) • Also occurs in children and the elderly
  6. 6. www.i-h-s.org
  7. 7. Primary Headache “Headache is an integral part of the syndrome…diagnosis is symptom based.” Secondary Headache “A de novo headache occurring with another disorder recognised to be capable of causing it….diagnosis is aetiological”
  8. 8. Headache Classification Part 1: The Primary Headaches Migraine Tension-type headache Cluster headache and other TACs Part 2: The Secondary Headaches Headaches attributed to:Head and/or neck trauma Cranial or vascular disorder Non-vascular intracranial disorder A substance or its withdrawal Infection Disorders of homeostasis Disorders of cranium/neck/eyes/ears/nose/sinuses Teeth/mouth Psychiatric disorder Part 3: Cranial Neuralgias
  9. 9. Life-time Prevalence of Symptomatic and Nonsymptomatic Headaches in a General Population Disorder % Migraine without aura Episodic TTH Idiopathic stabbing External compression Cold stimulus Benign Cough Headache Headache associated with sexual activity Hangover Fever Headache Head Trauma Metabolic (fasting) Disorders of the neck, eyes, ears Disorders of the nose/sinuses 9 66 2 4 15 1 1 72 63 4 19 1, 3, 0.5 15 Ref: Rasmussen and Olesen Neurology 1992;42:1225-1231
  10. 10. Differential diagnosis of 906 patients who presented to a general neurology clinic with headache or facial pain as the major or only symptom Diagnosis Number % Tension headache Migraine Headache ? Cause Post-traumatic Facial pain ?cause Depression Trigeminal neuralgia Cluster headache Malignant IC Tumour Benign IC Tumour Temporal arteritis Post-herpetic neuralgia Benign IC hypertension Cough headache Subdural haematoma Sinus infection 296 241 139 71 38 29 29 19 14 9 6 5 4 3 2 1 32 27 15 8 4 3 3 2 1.5
  11. 11. Primary Headaches 1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal autonomic cephalalgias 4. Other primary headaches – Primary stabbing/cough/exertional/sexual activity/thunderclap – Hypnic – Hemicrania continua – New daily-persistent headache
  12. 12. Migraine
  13. 13. Headache/Pain with Visual/Occular Symptoms or Signs Migraine Migraine without Aura Migraine with Aura Migraine Aura (No or little headache)
  14. 14. The burden of migraine Prevalence • Migraine is most common during the productive years 20 18 16 14 12 10 8 6 4 2 0 18.3% 14.3% 7.6% Age-related prevalence of migraine Migraine prevalence (%) % of UK population Gender-related prevalence of migraine 30 Females 25 Males 20 15 10 5 0 Overall Females Steiner TJ et al. Cephalalgia 2003; 23:519-527 Males 20 30 40 50 Age (years) 60
  15. 15. The burden of migraine Disability due to migraine Normal function Severe impairment/ bed rest 9% 53% 38% Some impairment • 91% of migraine patients report disability Lipton RB et al. Headache 2001; 41:646-657
  16. 16. Trigger Factors for Migraine 1. Stress – relaxing 2. Hormonal changes in women 3. Sleep deprivation/lying in 4. Dietary changes 5. Environmental stimuli 6. Combinations There may not be any!
  17. 17. The Triptans Imigran (Sumatriptan) Zomig Naramig Maxalt Relpax Almogran Migard
  18. 18. Preventative Drugs Beta-blockers eg propranolol, metoprolol, atenolol Epilim (sodium valproate) Topamax (topiramate) Tricyclic antidepressants eg amitriptyline Calcium blockers Sanomigran (pizotifen) NSAID’s
  19. 19. Tension-type Headache
  20. 20. Headache/Pain with Visual/Occular Symptoms or Signs Tension-type headache ? Due to refractive errors ? Due to squint ? Relate to wearing glasses
  21. 21. Cluster Headache
  22. 22. Horner’s Syndrome in CH • Appears during attack • May persist between attacks
  23. 23. Cluster Headache (Migrainous Neuralgia) • Fairly rare disorder - prevalence 0.1 % • Male:Female ratio approx. 5:1 • Usually a primary headache disorder; occasional post-traumatic cases, or rarely secondary to pituitary tumour or aneurysm • Occasional familial cases (4-7%) • Majority of sufferers enthusiastic smokers
  24. 24. Episodic Cluster Headache • • • • • • Onset typically 20-30, occasionally older Bouts of attacks lasting 1week to 4 months Bouts 1-2/year, often seasonal (spring, autumn) Sometimes long remissions lasting years Sensitive to triggers only in bouts 10-20 % go on to chronic CH
  25. 25. Headache/Pain with Visual/Occular Symptoms or Signs Primary Headache Syndromes Migraine Cluster headache and other Trigeminal Autonomic Cephalalgias (TACs) SUNCT (short-lasting, unilateral, neuralgiform headache with conjunctival injection and tearing) Cranial Neuralgia Trigeminal Neurlagia
  26. 26. Headache/Pain with Visual/Occular Symptoms or Signs • • • • • • • Corneal ulcer Sceritis/Episcleritis Glaucoma ?Retinal Migraine ?Opthalmoplegic Migraine Optic Neuritis Pituitary Tumours Are all Secondary Headaches
  27. 27. Serious Causes of Headache
  28. 28. Red Flags in Headache History • • • • • Sudden onset severe headache New headache in old people Headache with coughing/straining Persistent morning headache with nausea Steadily worsening headache Note: Serious causes of headache may have no abnormal signs
  29. 29. Dealing with Headache 1. Is it serious? The patient’s view 2. If not, what is it due to? Diagnosis? Explanation? 3. Management and treatment Goals. Realism

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