Steve Elliot
GPwSI Headache
 History taking in episodic headache
 History taking in chronic headache
 3minute neurological examination
 Who to refer for scanning
 (Management of headache)
“Listen to the patient. He is
telling you the diagnosis”
Sir William Osler (1849-1919)
“The headache history has to
be taken, not received”
Professor Peter Goadsby
Why does it matter?
 Headache is not a diagnosis
 Clear diagnostic criteria
 Diagnosis before treatment
 Disease specific treatments
Guatama Buddha 563-483 BC
How to relieve suffering
8 questions - the way to end
suffering in headache
 Location?
 Character?
 Severity?
 Aggravation by movement?
 Nausea/vomiting?
 Photophobia?
 Phonophobia?
 Duration?
IHS tension headache
2 of
 Bilateral
 Pressing./tightening/non pulsating quality
 Mild to moderate intensity
 Not aggravated by movement
No more than 1 of
 Nausea/vomiting
 Phonphobia or photophobia
Duration 30minutes to 7days
IHS migraine
Need 2 out of:
 Unilateral
 Moderate-severe
 Throbbing
 Worse with movement
Need 1 of
 Nausea and/or vomiting
 Photophobia and phonophobia
Duration 4-72 hours
SIGN guidelines
“Neuroimaging is not indicated in
patients with a clear history of
migraine,without red features for
potential secondary headache,and
a normal neurological
examination”
Cluster headache
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Side locked unilateral
Peircing /drilling/grinding
Very severe
Not worse with movement
Possibly nausea/vomiting
Possibly unilateral photophobia
Possible phonophobia
15-180 minutes duration
Autonomic symptoms
Restless
Landmark study
 1203 patients
 GP diagnosis of primary headache
 Headache diary for 3months
 Diaries analysed by blinded assessors
Findings:
 94% migraine or probable migraine
 82% “tension type headache” had migraine
“Brain attack”
 Trigger – Dorsal pons
 Prodrome - Hypothalmus
 Aura – Cerebral cortex
 Peripheral sensitisation – Cranial vasculature
 Central sensitisation – Thalamus
 Nausea/vomiting- Area Postrema
 Autonomic symptoms – Parasympathetic system
 Neck pain – Sensitisation of C2/C3
Why me?
Blame your parents
Chemical imbalance
Your brain is different
Symptoms between attacks
Chronic headache
 2-3% of population have headache on more
days than don’t
 Half of above have medication overuse
 2%/year migraine transforms to chronic
 Most preceded by episodic headache
 Co-mordidities anxiety,depression,obesity
 Difficult to manage
Causes chronic daily headache
Primary headaches
 Chronic tension type headache
 Chronic migraine
 Chronic cluster headache
 Medication overuse headache
 New daily persistent headache
 Hemicrania continua
History in chronic headache
 Pattern
Low grade all time?
Low grade with exacerbations?
Short lasting frequent?
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Stable or progressive?
8 questions
Medication including OTC?
Caffeine consumption?
Exclude red flags
What not to miss
 Idiopathic intracranial hypertension
 Low pressure headache
 Giant cell arteritis
 Other secondary headache
REMEMBER
 High pressure headache WORSE on lying flat
 Low pressure headache BETTER lying flat
How to perform a headache
examination
3minute headache examination
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Romberg
Palm drift
Pupil responses
Fields
Play piano
Finger-nose
Tandem gait
Facial movements
Eye movements
Fundoscopy
Protrude tongue
Limb and plantar reflexes
Corneal reflexes
Don’t forget
 BP
 Palpate temporal arteries >50
 ESR/CRP >50
 DOCUMENT WHAT YOU DO
Neuroimaging guidelines
- a brief summary
What do we know?
 Incidence of brain tumour in general population is
0.06-0.01% per year
 72% occur over age 50
 In primary care risk of brain tumour with headache
presentation is 0.09%
 If GP makes diagnosis of primary headache risk is
0.045%
 If GP cannot make diagnosis then risk is 0.15%
NICE, TWW and headache
 Headaches in whom a brain tumour is suspected
 Headache of recent onset accompanied by features
suggestive of raised intracranial pressure eg
Vomiting
Drowsiness
Posture related headache
Pulse synchronous tinnitus
Or by other focal or non-focal neurological symptoms eg
blackout,change in memory or personality
 New, qualitatively different,unexplained headache that
becomes progressively severe
But...
 Tension type headache 58-77% of brain tumours
 Migraine like in 7-9% but atypical features
 Intermittent headache in 62-88%
 8% headache as only symptom
 74% brain tumours present within 3months
 90% within 6 months
 Brain tumour headache may be similar to previous
headache but more frequent/severe and associated
with new symptoms
Red flags-SIGN guidelines
 New onset or change in patient
 Patients with risk factors for
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over 50
New onset headache with
history of cancer
Abnormal neurological
examination
Headache that changes with
posture
Headache that wakes (most
common migraine)
Headache precipitated by
physical exertion/Valsalva
Non focal neurological
symptoms eg cognitive
disturbance)
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CVST
Jaw claudication or visual
disturbance
Neck stiffness
Fever
Change in headache
frequency,characteristics or
associated symptoms
Thunderclap headache
Headache that changes with
posture
New onset in patient with HIV
Red flags-BASH guidelines
Risk of underlying tumour >1%
Warrant urgent investigation
 Papilloedema
 Significant alterations in
consciousness,memory,confusion or co-ordination
 New epileptic seizure
 New onset cluster headache (non urgent)
 History of cancer elsewhere particularly breast or lung
Orange flags -BASH
Probability of an underlying tumour 0.1-1%
Careful monitoring and low threshold for investigation
 New headache where diagnosis not clear after 8weeks
 Abnormal neurological exam or other neurological symptoms
 Headache aggravated by exertion or Valsalva’s manoeuvre
 Headaches associated with vomiting
 Headaches which have been present for some time but have
changed significantly, particularly rapid increase in frequency
 New headache in patient over 50
 Headache which wakes from sleep
 Confusion
Yellow flags- BASH
Probability of underlying tumour between 0.01 and 0.1%
Need for follow up not excluded
 Diagnosis of migraine or tension type headache
 Weakness or motor loss
 Memory loss
 Personality change
Acute medication in migraine
 Paracetamol
 Aspirin 900mg
 Naproxen 500mg
 Domperidone if nausea
 Consider suppositories
 Almotriptan 12.5mg
 Other triptan if Almotriptan ineffective
 Zolmitriptan nasal spray
 Sumatriptan injection
Prophylaxis
 Propranolol 80-240mg
 Amitriptyline 10-100mg
 Pizotifen if young
 Topiramate or Epilim
 Take 6-8 weeks to kick in
 See regularly
Don'ts in migraine treatment
 Over the counter
 Opioids
 Caffeine
 Migraleave
 Analgesia more than 2-3 days per week
Sir William Osler again
“One of the first duties of the physicians to
educate the masses not to take medicines”
Medication overuse headache
 Headache >15 day per month
 Intake of following for 3months
Simple analgesia >15 days per month
Or Opioids/triptans/combination analgesia >10 days
per month
 Headache resolves or returns to previous pattern
within 2months of discontinuation of analgesia
What do you do when you get a
headache?
 Stay still =Migraine
 Pace up and down = Cluster
 Take tablet = Medication overuse
Management of chronic headache
 Exclude red flags
 Establish phenotype
 Lifestyle measures
 Avoid caffeine
 Stop analgesia
 (Occasional Naproxen)
 Start prophylaxis according to phenotype
 Regular follow up
“ The very first step towards success in
any occupation is to become interested
in it”
Sir William Osler (1849-1919)
Canadian Physician