Adult with headache Problem-specific video guides to diagnosing patients and helping them with management and prevention London Strategic Clinical Networks London Neuroscience Strategic Clinical Network How to achieve a working diagnosis? 1 If headache duration less than 6 months, consider serious cause If headache duration greater than 6 months, serious cause unlikely If episodic headache Introduction If daily headache i.e. occuring greater than 50% of days and chronic headache to the types of episodic headache 5 6 What are the red flag features? 2 3-minute neurological exam A YouTube video by Dr Fayyaz Ahmed, consultant neurologist at Hull Royal Infirmary, on how to conduct a brief neurological examination Red flag features Diagnosing tension type migraine 5a 5b cluster 5c other 5d Headache impact test chronic migraine 6a Find out more When is a brain scan helpful? 3 A PDF questionnaire from the British Association for the Study of Headache to help patients communicate what they cannot do because of headaches Headache diary Acute treatment options Managing migraine 7 menstrual migraine 10 tension type 12 cluster Easy-to-use monthly and annual PDF diaries from the National Migraine Centre to help patients record information about headache attacks chronic tension type 6b Who to refer and where? 13 4 Healthline recommend the fourteen best migraine iphone and Android apps of 2014 medication over-use migraine medication 8 migraine and the contraceptive pill Acute treatment options Acute treatment options 6c List of the videos 11 new daily persistent If serious problem suspected If serious problem not suspected Refer patient to specialist headache services Consider other acute cause: TMJ dysfunction Cervicogenic headache Occipital neuralgia Sinusitis 6d Acute treatment options Preventing migraine 9 tension type cluster Prevention options Prevention options Prevention options If patient is responding Headache apps medication over-use If other secondary headache return to How to achieve a working diagnosis? 14 Prevention options If patient is not responding or there are complicating co-morbidities Management options About specialist headache services 15 Refer patient to specialist headache services Acknowledgements
Red flag features Progressive headache Sudden inset worst ever headache Jaw claudication and scalp tenderness Significant fever or systemic upset New altered headache in elderly New altered headache in immunocompromised New altered headache in patient with known malignancy Examination abnormal: Eye movements Fundi e.g. papilledema Pupils and pupillary reactions Limb and or gait ataxia Tendon reflexes / plantar
Migraine headache acute treatment options At headache onset: Analgesia: NSAID e.g. Ibuprofen 400 600 mg or Naproxen 250 500 mg Anti-emetic: e.g. Metoclopramide 10 mg, Domperidone 10 20 mg Sumatriptan 50 100 mg All up to 6 times / month
Tension type headache acute treatment options Analgesia: NSAID e.g. Ibuprofen 400 mg or Naproxen 250 500 mg PRN Avoid opiates and compound analgesia
Cluster headache acute treatment options Subcut injection 6 mg, Sumatriptan as needed for acute episode Nasal Sumatriptan or Zolmitriptan as needed Oxygen 100% 10 12 l/min for 10 12 mins Prednisolone 40 60 mg for 7 10 days
Other headache acute treatment options For neuralgia: Carbamazepine 200 800 mg daily on two divided doses
Migraine headache prevention options Identify / avoid / modify migraine triggers Propranolol 20 320 mg od Metoprolol 50 200 mg daily Topiramate 25 100 mg bd or Amitriptyline 10 150 mg nocte
Tension type headache prevention options Lifestyle and headache trigger avoidance Consider acupuncture
Cluster headache prevention options Verapamil 240 720 mg / day (with normal ECG)
Chronic medication over-use headache prevention options Reduce / stop analgesia Monitor with headache diary Further treatment based upon diagnosis e.g. migraine, tension type, etc.
Episodic headache management options For migraine, tension type and daily headaches: Monitor and adjust treatment Consider withdrawing preventative rx after 4 6 months Avoid increasing analgesic use
List of the videos 1 History taking History of presentation: headache history, medical history, treatment history. 2 Red flag Headache duration, headache characteristics, patient characteristics. Associated neurological and systemic features. Screening. Red flag features but not a red flag. 3 Brain scan and blood tests Use: diagnosis, anxiety. CT and MRI. Refining a diagnosis. Headache but a normal brain scan, discovery of abnormalities not linked to headache. Blood tests inflammatory markers. 4 Referral Diagnostic (urgent/non urgent. Referral pathways two week wait/a&e. Management neurology headache services). 5 Introduction: episodic headaches types 5a Episodic migraine diagnosis Headache characteristics, duration and intensity. 5b Episodic tension type headache diagnosis Headache characteristics. Migraine v tension type same or different. Approach to take. 5c Episodic cluster headache diagnosis Headache characteristics, attack patterns, severity, patient responses, triggers, why diagnosis can be missed. 5d Other episodic headaches Trigeminal neuralgia and cluster headache. Trigeminal autonomic cephalgia. 6 Introduction to chronic daily headache Definition and duration. 6a Chronic migraine common cause of daily headache Prevalence and characteristics. 6b Chronic tension type common cause of daily headache Characteristics. 6c Medication overuse common cause of daily headache Definition, analgesia thresholds/use, characteristics. 6d New daily common cause of daily headache Characteristics, primary and secondary. Secondary: spontaneous intracranial hypotension, intracranial hypertension, intracranial venous thrombosis. Primary: Hemicrania continua. 9 Migraine prevention When to use, patient explanation choices, licensed medication, dose level and patient tolerance, preventative duration, monitoring. 9 Menstrual migraine Timing, hormonal, menopausal, strategies: triggers & self-help, triptan, oestrogen replacement. 9 Migraine and contraceptive pill Combined contraceptive pill, risk, migraine with aura, alternatives. 12 Tension headache management Featureless headaches, underlying migraine, treatment, complementary strategies acupuncture, nutraceuticals, physiotherapy. 13 Cluster headache Treatment for acute attacks, treatment to shorten bouts, treatment to prevent bouts occurring. Acute attacks triptans, oxygen (Ouch uk https://ouchuk.org/sites/default/ files/downloads/home_oxygen_order_form_ parta_dv.pdf). Transitional treatment steroids, nerve block. Preventative medications. 13 Medication overuse Explanation to patient, treatment strategies, patient characteristics. 13 Specialist headache services Characteristics and conditions managed: time, expertise in use of rating scale, medication history, patient information, diagnostic investigations, treatment medication, nerve blocks, Botox, detox. 7 Migraine management Diary, patient discussion, avoiding headache triggers, self-help. 8 Migraine treatment Medication package analgesic, antiemetic, triptans. Doses and frequency.
Acknowledgements Pathway created and updated by Dr Bal Athwal, Consultant Neurologist, Royal Free London Hospital with contributions from Dr Nassif Mansour, GP, Kingston CCG Podcasts by London Neuroscience Strategic Clinical Network shared learning working group September 2014 Prof Lionel Ginsberg Dr Bal Athwal Dr Nassif Mansour Dr Philippa Curran Version 1.7 June 2015 London Neuroscience SCN