Transcript Document
Dr Adam Zermansky Consultant Neurologist
Managing Headache
(without breaking the bank)
Implementation of useful referral guidelines
G
reater
M
anchester
N
euroscience
C
entre
Managing Headache
(without breaking the bank)
Latest Greek Bailout Cost of Headache
€130 billion €173 billion
1 1 Eur J Neurol December 2011
Scale of the problem
• • • •
At least 10% population suffer from headache 1-2% suffer chronic migraine (>15 days/month) 4.4% per year consult GP for headache
1
20% of sickness absence from work
2 1 Latinovic R et al. JNNP 2006;77:385-387 2 Rasmussen BK. Cephalalgia 2001; 21:774-7
Salford GP Referrals to SRFT
2005 - 2009 4500 4000 3500 3000 2500
Neurology
2000 1500 1000 500
Neurosurgery
0 2005 2006 2007 Year 2008 2009 Cardiology Haematology Immunology Dematology ENT Gastro Gen Medicine Gen Surgery Gynaecology Neurology Neurosurgery Respiratory Rheumatology Orthopaedics Urology 35.0
30.0
25.0
20.0
15.0
Triage rate per 1000 Patients
Referral per 1000 patients 2008-9 10.0
5.0
0.0
1 3 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 5 7 9 Practices in descending order of referrals Audit results courtesy of Dr Jon Sussman
Many patients referred before trying treatment Referral Category
Low (3.4 – 4.9) Medium (5.1 – 7.5) High (>9) Very high Extremely high
% new onset headaches (<6 months)
37.7 40.3 43.8 38.9 20.0
% chronic headaches (>6 months)
62.3 59.7 56.3 61.1 80.0 100 90 80 70 60 50 40 30 20 10 0 Low Med Treated Untreated High V. High Extr. High Audit results courtesy of Dr Jon Sussman
Guidelines needed?
• • • •
Increasing referrals Many patients untreated Educational aid, easier than turgid BASH/SIGN Pilot in Salford: saved PCT £100,000 in 1 year
Adult with Headache
Emergency symptoms?
Yes
Headache Management Pathway
Refer to appropriate on-call hospital team • • • • • • • • • Thunderclap onset Accelerated/Malignant hypertension Acute onset with papilloedema Acute onset with focal neurological signs Head trauma with raised ICP headache (see red flags) Photophobia + nuchal rigidity + fever +/-rash Reduced consciousness Acute red eye: ?acute angle closure glaucoma New onset headache in: • 3rd trimester pregnancy/early postpartum • Significant head injury (esp. elderly/ alcoholics / on anticoagulants)
Adult with Headache
Emergency symptoms?
No Giant cell arteritis?
Yes Yes
Headache Management Pathway
Refer to appropriate on-call hospital team Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy) • • • Symptoms and signs: • jaw/tongue claudication, amaurosis, scalp tenderness • temporal artery: prominent, tender, diminished pulse • other cranial nerve palsies, limb claudication • PMR Many headaches respond to high dose steroids, so do not use response as the sole diagnostic factor ESR can be normal in 10% (check CRP as well) www.rheumatology.org.uk/includes/documents/cm_docs/2010/m/2_management_of_giant_cell_arteritis.pdf
Adult with Headache
Emergency symptoms?
No Giant cell arteritis?
No Red flags?
Yes Yes Yes
Headache Management Pathway
Refer to appropriate on-call hospital team Refer Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy) •Raised intracranial pressure:- •Wakes from sleep (but not migraine or cluster) •Precipitated by Valsalva manoeuvres (cough, straining at stool) •Papilloedema •Other symptoms of raised ICP headache include: o Present upon waking and easing once up (MOH can cause this phenomenon) o Whooshing pulse-synchronous tinnitus o Episodes of transient visual loss when changing posture (e.g. upon standing) o Vomiting (in context as migraine causes this!) •New onset seizures •Persistent new or progressive neurological deficit •Increasing in severity and frequency despite appropriate treatment •Undifferentiated headache of recent origin and present for >8 weeks •Triggered by exertion •New onset headache (< 6 months) in:- >50 years old (consider giant cell arteritis); interrogate patient about previous ‘normal headaches’ as it might not be ‘new’ Immunosuppressed / HIV / relevant history of cancer
Adult with Headache
Emergency symptoms?
No Giant cell arteritis?
No Red flags?
No
Migraine
or
tension headache
?
Yes Yes Yes
Headache Management Pathway
Refer to appropriate on-call hospital team Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Refer Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy)
Primary or Secondary?
Categorisation: Primary
Categorisation: Secondary
The 1 in 10,000 problem…
Migraine
Brain Tumour Headache
• • • What symptoms did they have before?
Headache: What % have BT?
BT: What symptoms do they have now?
Brain Tumours: symptoms
BJGP 2007
6 months Tumour Control
(any)
Population risk 0.01%
Headache: secondary causes
What happens to new-onset headache presented to primary care?
A case-cohort study using electronic primary care records D Kernick, S Stapley, PJ Goadsby & W Hamilton Cephalalgia 2008
Undifferentiated headache
Brain tumour 0.15% 1 in 1250 <50 1 in 360 >50
Primary headache
Malignant brain tumour 0.045% i.e. 1 in 2222 Background BT incidence 0.013 %
Brain Tumour Headache: What’s it like?
• • Headache common 50% of patients – Bland, featureless – Episodic – Responds to simple analgesic – New or change pattern Raised ICP type headache is rare (5.1%)
Head scan / referral?
• • • • • Raised ICP headache – Early morning / waking – Valsalva or exertion triggered Bland unclassifiable headache in over 50s (take proper history) New onset / change in headache – >50y – HIV – Cancer – thrombotic tendency Headache+ – GCA, atypical aura, seizures, fever and neck stiffness, thunderclap, abnormal neurology ?? Therapeutic scan
Therapeutic scan and VOMIT
• • GP reassurance < 1y patient reassurance • Incidentaloma: 1 in 37 • Cysts • • • • • • aneurysms Vascular anomalies Inflammatory Developmental (AC) WML Neoplasms
Messages
• • • • • Brain tumours rare (1/10k) Primary headache: brain tumour still rare Diagnose the headache type Think about red flags, even if primary headache Caution: VOMIT from ‘therapeutic scans’
Migraine
• • • • Unilateral onset Throbbing 4 – 72 hours Sensory Sensitivity – Light – Sound – Smells – Movement
migraine behaviour
Common misdiagnosis of migraine
• • • • • • • Cervicogenic Headache (30% migraine→neck pain) Chronic Tension Type Headache Eye Strain Dental TMJ dysfunction Sinus headache Hypertensive Headaches
IHC II aura
• • •
focal neurological symptoms
develop over 5-20 minutes last for < 60 minutes
Vauban 17 th century
Aura
• • • • • • Fortification spectra = teichopsia Photopsia Scotoma Shimmering Paraesthesia Hemiparesis
Pain
Cluster Headache Autonomic Agitation
www.ouchuk.org
Lasts 30 – 120 minutes ?? Glaucoma
Migraine Treatment: acute
• • • Aspirin 900mg + metoclopramide (and/or paracetamol) NSAID Triptans: 5-HT 1b/d agonists – Almotriptan – – – – – Eletriptan Frovatriptan Naratriptan Rizatriptan Sumatriptan Generic and fastest acting • • Antipsychotics: chlorpramazine etc Steroids?
Migraine Treatment: Prophylaxis
• • • • • Propranolol Amitriptyline (pizotifen….no evidence…..gain weight and sleepy) Topiramate – Wt loss, paraesthesia common – Memory problems, 1% renal calculi Gabapentin • • unusual stuff: Botox, methysergide, lisinopril...
Alternative stuff: – Feverfew+riboflavin, butterburr, Mg, acupuncture
BMJ 2011;342:d583
Pharmacological Prevention of Migraine
Adult with Headache Headache Management Pathway
Emergency symptoms?
No Giant cell arteritis?
No Yes Yes Refer to appropriate on-call hospital team Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology (consideration of temporal artery biopsy) Red flags?
No Yes Refer
Migraine
or
tension headache
Yes ?
No Yes Cluster headache?
Try acute treatments No Secondary causes?
e.g. sinusitis, TMJ pain Hb, Ca 2+ , TFT,ESR, CRP R/V lifestyle & medication Treat as necessary Prescribe acute treatment (< 10 times/month) Refer Still troublesome?
Yes No
Suspect:-
• Medication overuse headache (MOH)?
• Drug induced?
Yes • If relevant, stop combined oral contraceptive • Ensure not overusing analgesics or triptans • Modify lifestyle (adequate sleep, hydration, reduce caffeine intake, trigger avoidance) • If prophylaxis necessary, try the following for 3 months at the target dose before judging efficacy:-
Migraine prophylaxis
a) Propranolol SR 80mg o.d. increase gradually to 240mg o.d. or maximum tolerated below that b) If ineffective or contraind: Amitriptyline 10mg o.n. increasing by 10mg/week to ≤75mg c) Don’t bother with pizotifen (weight gain, sedation, little benefit) d) If above ineffective/not tolerated, try Topiramate 25mg o.d. increasing by 25mg every 2-weeks aiming for a target of 50mg b.d. NOTE: teratogenic and potential interaction with combined oral contraceptive
Tension Type Headache prophylaxis
Amitriptyline 10mg o.n. increasing by 10mg a week up to 75mg or maximum tolerated below that Yes Stop offending medication (for 2 months if MOH) Can you diagnose migraine or tension headache?
Still troublesome?
Yes No Continue treatment for 9-12 months; then consider stopping No further treatment Still troublesome?
Yes No No
What the patient thinks…..
x x
The reality…..
Scan Primary headache: Play 3 games to find 1 tumour