Headaches

1
Headaches

• Dr Mark Silva

2
Outline

• Cases
• Headaches
• Cases
• Conclusion

3
Headaches
4
Case 1

• 44 year old business man
• 3 week history of intermittent severe right eye
  pain
• Lasts about 1 hour, eye goes red, paces about.
  No sickness. Occurs 2-3 times a day.
• What is the diagnosis?
• Other features?
• Investigations?
• Treatments?

5
Case 2

• A 34 year old man presents in surgery.
• 4 days before, while walking, he had a sudden
  severe headache that had stopped him in his
  tracks. He still had a mild headache.
• He occasionally got migraine with aura but this
  was quite different. Examination normal.
• What is the diagnosis?
• What do you do?

6
Case 3

• 78 year old lady
• Always fit and well
• 4 weeks history of thick headache. Feels out of
  sorts.
• Never really had headaches.
• No signs on examination
• What is the diagnosis?
• What do you do?

7
Case 4

• 48 year old housewife with mild asthma
• Generalised headache over the last 5 months,
  present all the time. Present morning on waking.
  
• Examination normal. Retinal venous pulsation
  present.
• What is the diagnosis?
• What do you do?

8
Case 5

• 45 year old woman normally fit and well long
  history of infrequent migraine
• New type of headaches over last 10 months
  occipital last 3-6 hours with nausea occur
  once every 2-3 weeks.
• Examination is normal
• What is the diagnosis?
• What do you do?

9
Case 6

• 29 year old man normally fit and well history
  of very occasional migraine
• Sudden onset severe occipital headache - during
  intercourse, onset at point of orgasm
• Examination is normal
• What question do you ask?
• What is the diagnosis?
• What do you do?

10
Case 7

• 43 year old woman gradual onset of headache
  sometimes occipital, sometimes generalised.
• Minor fall from childrens slide onto buttocks.
  Irritating cough
• Exacerbated by standing or sitting, coughing,
  sneezing
• Examination is normal
• What is the diagnosis?
• What do you do?

11
Case 8

• 21 year old woman normally fit and well.
• Headache bifrontotemporal, blurry vision,
  noise in ears
• Examination Obese, constricted visual fields
  papilloedema
• What is the diagnosis?
• What do you do?

12
HeadacheIn a population of 2,000
13
Headache in a population of 2,000
14
Headache
Different Models Patient Brain tumour
others Doctor Dangerous Non-dangerous
15
Dangerous headaches

• Temporal arteritis
• Subarachnoid haemorrhage
• Meningitis
• Raised intracranial pressure
• Features
• Late in life
• sudden onset
• progressive
• associated neurology

16
(No Transcript)
17
Red flags - Headache

• Sudden severe headache
• Difficult to assess
• Doctors poor at predicting which.
• Delay is common and dangerous
• 51 of SAH diagnoses delayed
• Worse outcome (43 vs 68 good recovery)
• Initial diagnoses none 65 migraine 14 viral
  illness/meningitis 14.

18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
Raised intracranial pressure

• Causes
• Mass
• Obstructive hydrocephalus
• Benign intracranial hypertension
• Clinical features
• Generalised and progressive
• worse on cough, sneeze and movement
• usually associated with other physical signs

22
Raised intracranial pressure

• 40 of brain tumours have NO headache
• 15 headache is first symptom
• series of 1,000 CT scans of headaches without
  signs - no tumours.

23
(No Transcript)
24
(No Transcript)
25
White flags
Headaches of over 6 months duration are not
dangerous Headaches after head injury -
migraine like
26
Safe but unpleasant headaches

• Migraine without aura
• Migraine with aura
• Cluster headache
• Tension headache
• Also
• Benign coital cephalagia
• Ice pick headache
• idiopathic paroxysmal hemicrania

27
Safe but unpleasant face pains

• Trigeminal neuralgia
• Atypical facial pain
• Temporomandibular syndrome
• Cluster headache
• Sinus pain

28
Migraine

• 6 males 16-20 females
• UK 90,000 absent from work each day
• 1.5 billion/year
• 2/3 self medicate with OTCs
• 1/3 use POMs
• 75 will consult GP at some time

29
Migraine - Phases

• Prodrome 60
• Aura
• Headache phase
• Headache resolution

30
Migraine - Prodrome

• Mental state - Depressed, hyperactive, euphoric,
  talkative, irritable, drowsy, restless
• Neurological - Photophobia, poor concentration,
  phonophobia, dysphasia, hyperosmia, yawning.
• General - Neck stiffness, food cravings, cold
  feeling, anorexia, sluggish, diarrhoea or
  constipation, thirtst, urination, fluid retention

31
Migraine - aura

• Complex of focal neurological symptoms
• ve or ve
• Develop over 5-20mins last less than 60mins.
• Visual, sensory, motor, language
• Headache usually within 60mins
• Headache follows aura 80 of time

32
Migraine - aura

• Visual scotomata, phosphenes, shimmering or
  undulations, teichopsia or fortification spectra.
• Paraesthesias typically arms face, ½ become
  bilateral
• 18 motor symptoms
• 17-20 aphasic auras

33
(No Transcript)
34
Migraine - Headache

• Unilateral, throbbing, exercise increases
• 40 bilateral at onset
• Most frequent in morning
• Onset gradual
• 4-72 hours
• throbbing 85

35
Migraine - Headache

• 90 nausea
• 1/3 vomiting
• Average 5 (on 0-10 scale)
• Photophobia, phonophobia, osmophobia

36
Migraine - Resolution

• Tired, washed out, irritable, listless, poor
  concentration, scalp tenderness, mood changes.
• Refreshed, euphoric
• Depression, malaise

37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
HeadachesQuestions Answers
41
Case 1

• 44 year old business man
• 3 week history of intermittent severe right eye
  pain
• Lasts about 1 hour, eye goes red, paces about.
  No sickness. Occurs 2-3 times a day.
• What is the diagnosis?
• What do you do?

42
Case 1

• Cluster headache
• Acute triptan (74 in 15 mins), oxygen 100 7
  l/min (82 in 15 mins)
• Prophylactic Verapamil (120-1200mg/day) or
  Valproate
• Occasionally steroids
• Lithium (300 900mg/day)

43
Case 2

• A 34 year old man presents in surgery.
• 4 days before, while walking, he had a sudden
  severe headache that had stopped him in his
  tracks. He still had a mild headache.
• He occasionally got migraine with aura but this
  was quite different. Examination normal.
• What is the diagnosis?
• What do you do?

44
Case 2

• Possible subarachnoid
• Medical admission for CT and LP
• Investigation now may avoid angiography

45
Case 3

• 78 year old lady
• Always fit and well
• 4 weeks history of thick headache. Feels out of
  sorts.
• Never really had headaches.
• No signs on examination
• What is the diagnosis?
• What do you do?

46
Case 3

• Probable temporal arteritis
• Start steroids
• Check ESR
• Arrange temporal artery biopsy ASAP

47
Case 4

• 48 year old housewife with mild asthma
• Generalised headache over the last 5 months,
  present all the time. Present morning on waking.
  
• Examination normal. Retinal venous pulsation
  present.
• What is the diagnosis?
• What do you do?

48
Case 4

• Tension-type headache
• Amitriptyline
• Relaxation exercises

49
Case 5

• 45 year old woman normally fit and well long
  history of infrequent migraine
• New type of headaches over last 10 months
  occipital last 3-6 hours with nausea occur
  once every 2-3 weeks.
• Examination is normal
• What is the diagnosis?
• What do you do?

50
Case 5

• Migraine
• Avoid triggers
• Acute treatments
• OTC
• Triptans
• Prophylaxis

51
Case 6

• 29 year old man normally fit and well history
  of very occasional migraine
• Sudden onset severe occipital headache - during
  intercourse, onset at point of orgasm
• Examination is normal
• What question do you ask?
• What is the diagnosis?
• What do you do?

52
Case 6

• Has it happened before?
• Yes, many times
• Benign Coital Cephalgia
• No treat as SAH
• Benign Coital Cephalgia
• Treatment nil?
• Beta-blockers

53
Case 7

• 43 year old woman gradual onset of headache
  sometimes occipital, sometimes generalised.
• Minor fall from childrens slide onto buttocks.
  Irritating cough
• Exacerbated by standing or sitting, coughing,
  sneezing
• Examination is normal
• What is the diagnosis?
• What do you do?

54
Case 7

• Low pressure headache
• Gadolinium enhanced MRI brain
• CSF analysis (OP 0-7cm)
• Radioisotope Cisternography
• Bed rest, increase fluids analgesia
• Abdominal binding!
• Theophylline or caffeine
• Blood patching (10-20mls) 96.8 in post-LP
  85-100 for others

55
Case 8

• 21 year old woman normally fit and well.
• Headache bifrontotemporal, blurry vision,
  noise in ears
• Examination Obese, constricted visual fields
  papilloedema
• What is the diagnosis?
• What do you do?

56
Case 8

• Benign intracranial hypertension (BIH or IIH)
• Normal brain imaging
• CSF raised OP
• Tap CSF
• Weight loss
• Acetazolamide 500mg bd 1g bd
• Surgery LP shunt or fenestration of ON

57
Headache

• Make a positive diagnosis
• BASH Guidelines online
• www.migraine.org.uk
• OUCH
• www.clusterheadaches.org.uk

58
Thank you
59
IHS Classification

• A 5 attacks fulfilling B-D
• B 4-72 hours
• C 2 of
• unilateral pulsating quality moderate to
  severe aggravated by exercise.
• D One of 1 N /or V
• 2 photo- phonophobia

60
Migraine Treatment Acute

• NSAIDs
• Ergotamine dihydroergotamine
• 5-HT1 agonists eg. Imigran 80 relief (but 40
  headache recurs).
• Migramax

61
Migraine - Prophylaxis

• Beta-blockers (55-84 efficacy at 80- 240mg/day)
• Pizotifen (50 have 50 reduction)
• Tricyclic antidepressants
• Methysergide
• Calcium antagonists
• Anticonvulsants

62
Migraine prophylaxis

• Epilim chrono
• Optimum dose 500 600mg
• Frequency reduced 3.5 to 2.0/month
• Headache days 6.4 to 3.5
• Kinze et al Headache 2001

63
Migraine - prophylaxis

• Lisinopril10-20mg
• Over 50 reduction in days without migraine
• Schrader et al BMJ 2001

64
Migraine - prophylaxis

• Magnesium 500mg OD
• Vitamin B2 400mg OD
• Co-enzyme Q10 150mg/day
• freq 4.85 to 2.81 61.3 had 50 reduction,
  93.5 had 25 reduction.
• Ginger
• Melatonin

65
Migraine prophylaxis trials

• PFO closure MIST trial
• Occipital nerve blocks
• Botox