Headache Giles Elrington 22 October 2018 [email protected] Headache demography Population Risk of serious cause • 95% lifetime • Primary care 0.1% • 75% annual • Neuro OPD 1% • 20% of women have • A&E 10% migraine • 2% have daily headache Headache diagnoses Primary headache Secondary headache • Migraine • Mass lesions – Nausea/vomiting – Seizures – Photo/phono – Progressive impairment – – Preference rest Signs • Subarachnoid haemorrhage • Tension type headache – Thunderclap • Medication overuse • Meningitis – >3 analg/week • High pressure – >2 triptans or opiates/week • Low pressure • Trigeminal autonomic cephalalgia (incl. cluster & hemicranias) • Vascular – – Side locked Arteritis – Ocular autonomic – Trigeminal neuralgia Two types of headache • Acute new headache – May need emergency management • Chronic headache – Does not need emergency management • Acute on chronic: challenging! Acute headache 1-2% of ED attendances – Subarachnoid haemorrhage (SAH) – Arterial dissection – Angiitis – Meningitis – Tumour – Vascular malformation – Reversible cerebral vasoconstriction syndrome – Sinus thrombosis Sayer et al Academic Emergency Medicine 2015 Subarachnoid haemorrhage • Thunderclap headache is key symptom • BMJ Clinical review 9 Jan 2013 BMJ2013;346doi: http://dx.doi.org/10.1136/bmj.e8557 • Sayer et al Academic Emergency Medicine 2015 Acad Emerg Med. 2015 Nov;22(11):1267-73. doi: 10.1111/acem.12811. Epub 2015 Oct 19 • Headache max in <5 minutes lasting >1hour • 1:10 ambulant thunderclap patients have SAH NCEPOD audit SAH 2013 Dilemma in diagnosis of thunderclap headache • Conventional approach – CT brain – CSF analysis if CT –ve – MRI brain? • Unconventional approach – CT brain – CT angiogram – MRI – No LP Why unconventional approach? Audit of 1898 LPs from 2278 CT -ve ?SAH patients in ED • 80% -ve CSF • 15% inconclusive • 5% positive (n=92) – Aneurysm n=8 (0.4% of LPs) – Carotid cavernous fistula (n=1) Epidemiology Aneurysm & SAH • Aneurysm • SAH 3-6% of population 6/100,000/year Causes of thunderclap headache • SAH • Primary thunderclap headache • Primary stabbing headache (usually brief) • Exertional & sexual headache • Reversible encephalopathy/ cerebral vasoconstriction syndrome Hemiplegic migraine sporadic & familial prevalence equal What happens The evidence base ichd-3.org A. At least two attacks fulfilling criteria B and C 1. Admitted on stroke pathway B. Aura consisting of both of the following: 1. fully reversible motor weakness 2. Normal imaging 2. fully reversible visual, sensory and/or speech/ language symptoms 3. Diagnose hemiplegic C. At least two of the following four characteristics: 1. at least one aura symptom spreads gradually migraine over 5 minutes, and/or two or more symptoms occur in succession 2. each individual non-motor aura symptom lasts 5–60 minutes, and motor symptoms last <72 hours 3. at least one aura symptom is unilateral3 4. the aura is accompanied, or followed within 60 minutes, by headache D. Not better accounted for by another ICHD-3 diagnosis, and transient ischaemic attack and stroke have been excluded. Medication Overuse Headache: Definition • Headache > 15 days/month ≥ 3 months and • ≥3 months – Triptans ≥ 10 days/month • i.e. ≥ 2d/week – Opioids ≥ 10 days/month • i.e. ≥ 2d/week – Combination medications ≥ 10 days/month • i.e. ≥ 2d/week – Simple analgesics ≥ 15 days/month • i.e. ≥ 3d/week Percentage of headache patients (n=9317) imaged 1994-2016: personal series 33.3% of total practice 70 60 50 40 CT or MRI MR CT 30 CT and MRI 20 10 0 1990 1995 2000 2005 2010 2015 2020 Incidentalomas Morris et al BMJ 2009;339:547-550 • Systematic review and meta-analysis of MRI brain scans of 19,559 ‘normal’ subjects • Neoplastic, structural vascular, inflammatory lesions, cysts, other structural lesions. Excluded: ‘white matter hyperintensities’, silent infarcts, microbleeds Lesion Prevalence % ‘NNS’ Neoplasms Meningioma 0.29 (0.13-0.51) 345 Pit. Adenoma 0.15 (0.09-0.22) 667 Low grade glioma 0.05 (0.02-0.09) 2000 TOTAL 0.7 (0.47-0.98) 143 Other 2.0 (1.13-3.10) 50 TOTAL 2.7 37 One of these six has no headache…which one is it? Treatment of migraine Infrequent or acute Frequent or chronic • Aspirin 900mg or ibuprofen • Address medication overuse 600mg, in water, plus • Lifestyle hygiene domperidone 10mg • Regular prophylactic • Triptan – NSAID • Consider triptan + NSAID + – Beta blocker domperidone – Tricyclic – Antiepileptic – Botox – GON block Migraine lifestyle treatments (lifestyle hygiene) • Regular body clock (sleep pattern) • Regular meals (breakfast at home) • Good hydration 2 litre water daily • Caffeine max 2 coffees or colas daily • Unchanging stress • Unchanging female hormones • Not dietary exclusion! • Not stress management! Three phases of migraine medication • Hours/one day – Triptan ± NSAID ± domperidone • Days/weeks – No evidence base – Address incipient medication overuse – Consider regular NSAID • Months/years – Conventional drug prophylaxis 22 Triptans: doing it right Target: pain free @ 2 hours in 90% of attacks • Treat soon after pain onset • Treat recurrence 1-2 x a day, if effective • No repeat dose if ineffective • Max 9 days a month • Consider – Non-oral formulation – Add • NSAID • Domperidone Triptans: doing it wrong • Therapeutic trial (to aid diagnosis) • In anticipation of pain (e.g. aura, prodrome) • Repeat following ineffective dose • Dose ≥ 10 days/month for ≥ 3 months • Fractions of tablets Preparing for prophylaxis • Optimise acute therapy • Address lifestyle hygiene • Exclude medication overuse • Review previous prophylaxis • Maintain headache diary • Agree goals Migraine prophylactics Target: 50% reduction attack frequency • Nutraceuticals & supplements – Vitamin B2 400mg daily (unlicensed) • Cardiovascular drugs – e.g. beta blockers (not all licensed) • Antidepressants – tricyclic or SNRI not SSRI (mostly unlicensed) • Antiepileptic drugs – e.g. topiramate (or valproate – unlicensed) • Serotonin drugs – Pizotifen (not NICE recommended) • Botox (chronic migraine) 26 Prophylaxis principles • Start lowest possible dose • Biphasic dose titration – Tolerability – Efficacy • Treat 3 for 12 months • Record outcome – Dose & duration – Pre- and on- treatment attack frequency 27 .