7. NICE 2012
• Do not scan primary headaches
for reassurance
8. 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
9. 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
12. 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
13. Prophylaxis – general principles
• Given if affecting QOL
• Titrated slowly
• Trial 6-8 weeks
• If effective consider withdrawal after 6-
12/12
14. Prophylaxis
• Propranolol LA 80mg - 240mg
– Caution asthma, bradycardia, PVD
• Topiramate 25mg – 50mg bd
– Caution kidney stones/depression/teratogenicity?
• Amitriptyline 10mg – 75mg
– Good if chronic/mixed
• Valproate 800-1200mg/day
– Caution young women
• Gabapentin up to 2400mg/day
• Pizotifen minimal benefit
18. Differential Diagnosis
• Drugs
– Da blocking drugs
• Antipsychotics
• Antiemetics
– Inhalers – B agonists
– Ca channel blockers
– Li
– Valproate
– Digoxin
• etc
• PD
• Thyrotoxicosis
– Check TFTs
• Anxiety
• ET
• Dystonic
19. Essential Tremor
• Activity
• Bimodal age onset
• ½ alcohol benefit
• ½ FH
• Postural/action, symmetrical 4-12 Hz
• +/- head (late), jaw, voice
• Treatment
– Propranolol LA 80mg – 240mg, Topiramate 25mg
– 100mg
– primidone, gbp.
– Rarely: deep brain stimulation
20. Peripheral neuropathy – history, investigations
and who to refer?
• Sensory (occ motor) disturbance feet
• Feet before hands
• Worse at rest/night
• Exam – reduced/absent AJ
• Investigations:
– Glucose, HBA1C, TFT, B12, Folate, ESR,
Autoantibodies, Igs and electrophoresis
• Refer – if motor symptoms +/or significant
sensory symptoms and no cause found
21. CTS/ulnar
CTS – most common cause of
sensory disturbance hands –
night + carrying
Thumb abduction/sensory
Open access NCS
Ulnar – small muscles
hand/sensory
Refer neurology
22. GP Q&A
Dr Martin Duddy
Consultant Neurologist
Royal Victoria Infirmary
Newcastle upon Tyne, UK
23. review of how to do a quick neuro
exam
• “brief neuro exam 2016”
• U of Birmingham; David Nicholl
• https://www.youtube.com/watch?v=q56WgXvn0iU
24. what test reliably rules out MS?
• composite diagnosis
• depends on degree of clinical suspicion
• normal MRI with significant symptoms
– role of spinal MR
• good story (esp with signs)
– evoked potentials
– LP
25.
26. when to suspect MS in sensory
symptoms
• anatomical distribution
• time course
• linguistics
• concordant motor/autonomic symptoms
• signs
27. MS: common pitfalls in dx,
e.g. what’s been missed by GPs
• sensitivity/specificity
• misdiagnosed past episodes
• missed symptoms
– bladder/bowel
– erectile dysfunction
– Lhermitte’s
– Uthoff’s (heat-sensitive symptomatology)
28. management/referral for abnormal
sensation, i.e. pins and
needles/numbness tingling
• clinical context
• is the distribution consistent with:
– peripheral mononeuropathy
– peripheral neuropathy
– radicular pathology
– myelopathy
– central disease
• does the time course suggest pathological process?
• congruent motor/autonomic/reflex changes
• is the presentation predominantly neurological?
– pain/ fatigue/ anxiety
Editor's Notes
Open access CT
Bo tox stopped if <30 reduction headache days per month after 2 cycles, or if changes to episodic migraine <15/7 per month for 3/12
