Transcript Migraine Management : Why 5HT's

I’ve got a
headach
e
???
Headache
David Kernick
Exeter Headache Clinic
Migraine impact
 Headache in top 10 of WHO disability index.
20% population – headache impacts on their quality
of life (adults and children)
£3 billion per year in economic terms
When people come to see you
what do they think they have?
When people come to see you
what do they think they have?
Need glasses
Blood pressure
Brain tumour
What do patients have when
they present to GP with
headache?
What do patients have when
they present to GP with
headache? Landmark Study
 85% migraine
 10% Tension type headache
 5% secondary headache
 <1% other types of headache
40
60
80
100
(Kernick 2008)
0
20
Percentage
What do GPs think when patients present with
headache?
20
40
60
Age
80
Cluster
Migraine
Tension
Secondary
Undifferentiated
100
Headache consultations in
primary care
 Consultation rates are low. 50% of migraine
sufferers have never seen a doctor
 10% are under continuing care
 One third of headaches will be incorrectly
diagnosed.
What is happening in primary
care?
Less than 20% will receive Triptan
Walling 2006
10% of those who would benefit from
prevention receive it
Rahimtoola 2005
Headache referral patterns
 9% GP presentations are referred to
secondary care (25% children)
(Loughey)
 20 - 30% of neurology referrals are for
headache
(Hopkins)
What do patients have when
they present to A and E with
headache? Valade 2000
n – 9480
Average age 37
250 admitted (3%)
 Migraine
 TTH
 Cluster
 Trauma
 Trig Neuralgia
 Sinusitis
 Vascular disorders
 Low Pressure
 Meningitis
 Tumour
 Other Misc
55%
25%
7%
1.6%
1.6%
1.6%
1.2%
1.2%
0.35%
0.17%
< 5%
Case 1
 35 year old male
 Three week history
 Sharp, severe pain bilaterally and posteriorly
lasting 10 seconds repetitively.
 One question?
 Two examinations?
 Would you investigate?
Classifying headache
Where does the pain come from?
Intra – cranial (dural pain fibres)
Tension – raised intracranial pressure
Compression – tumour
Inflammation - migraine,meningitis,blood
Where does the pain come from?
Extra - cranial
Arteritis
Neuralgia
Muscle tension
Facial structures
IHS Headache classification
Primary
 Migraine
 Tension type
 Autonomic cephalalgias
(cluster)
Secondary







Traumatic
Vascular
Non-vascular (SOL)
Substance induced
Infection
Disturbed homoestasis
Facial structures
Activation anywhere
in the system
can lead to output in
any other part
of the system and
vici versa
Secondary Headaches
AURA
Thalamus +
Mid Brain structures
Medication
overuse
headache
Tension type
headache
Hypothalamus
CLUSTER
CERVICAL
NUCLEI
MIGRAINE
CENTRE
Headache model
Primary
Headaches
Case 1
 35 year old male
 Three week history
 Sharp, severe pain bilaterally and posteriorly
lasting 10 seconds repetitively.
 One question?
 Two examinations?
 Would you investigate?
Two examinations
Fundoscopy
BP
Giles Elrington neurological examination
Case 1
 35 year old male
 Three week history
 Sharp, severe pain bilaterally and posteriorly
lasting 10 seconds repetitively.
 One question?
 Two examinations?
 Would you investigate?
Headache Pathway
EXCLUDE A SECONDARY HEADACHE
 Do something now
 Do something soon
 DIAGNOSE A PRIMARY HEADACHE
 Exclude medication overuse and manage the
primary headache
Case 2
You are called out to a 21 year old female
who has had severe sudden onset
headache. She is lying in a darkened room
vomiting and is unable to move.
What is the differential diagnosis?
Sub Arachnoid - thunderclap headache
Thunderclap headache - RVS
 lasts 1-3 mths.
Primary or secondary
Normal CT, LP. Needs CT angio.
Can get complications
Meningitis
Malignant hypertension
Migraine - The emergency call
out
Injectable sumatriptan
I.M. Diclofenac and anti-emetic
Avoid opiates
Sort out the migraine
Case 3
55 year old male.
New headache. L temporal. Fluctuating
in intensity. Featureless. Examination
normal.
What would you do?
Temporal arteritis
•Can be bilateral
•Systemically unwell
•Tender artery with allodynia
•CRP better than ESR
•Problem with skip lesions
CASE 4
•26 year old pole dancer
•Headache with intercourse
•What questions would you ask her?
•Any investigations?
•Treatment?
Sex headache
 Pre orgasmic or orgasmic (10% SAH)
 Primary or secondary (vascular, tumour,
Arnold Chiari)
 Low threshold for investigation
 Treatment




Technique
B blocker
Indometacin
Avoid recreational drugs
Non specific headache
Tinnitus
Two examinations
What is most likely diagnosis?
Low Pressure Headache
Case 5
A 34 year old man presents with pain
around his left eye that he describes like a
“red hot poker”. He has had a number of
attacks over the last few weeks.
With this presentation, what are the key
questions you need to ask him to establish
a diagnosis?
What investigation will you do?
Cluster - Autonomic
Cephalopathy
High impact ++
Peri-orbital clusters 15mins - 3 hours
Cluster attacks and periods
Unilateral autonomic features
Acute or chronic
Cluster treatment
 Injectable Sumatriptan
 Nasal Zolmitriptan
 Short term steroids
 Oxygen 100%
 Verapamil
CASE 6
 45 year old female
 Dull continuous bilateral occipital pain
 Featureless
 Worried as friend had brain tumour and wants
a scan
 Three questions?
 Do you investigate?
Have you ever had migraine?
Do you have problems with your neck?
What pain killers are you taking?
To scan or not to scan?
Medication overuse headache
Headache intensity
Withdrawal of all analgesia
Increased frequency of headache,
associated with increased frequency
of analgesia use.
Daily headache
with spikes of more
severe pain
Migraine attacks
Frequent ‘daily’ headaches
Return of episodic
headache
Primary Tumours
Meningioma 20%
- 10 yr survival 80%
Glioma 70%
- 5yr survival 20%
Misc. 10%
- Variable
Headache and tumour
Headache prevalence with tumour
70%+
Headache at presentation
50%
Headache alone at presentation
10%
(Iverson 1987)
Risk of brain tumour with headache
presenting to primary care (Kernick 2008)
Risk %
Undifferentiated
headache
Primary headache
Under 50
0.09%
0.03%
Over 50
0.28%
0.09%
We need to scan when the
advantages out way the
disadvantages
Reassurance,
Diagnosis/treatment
Cost, exposure
incidental pathology
(4-10%)
Luftwaffe pilots (n-2370)
Weber 2006
93% normal (25% variations of norm)
6.7% abnormalities
56 cysts; 13 vascular abnormalities;4
adenomas; 4 tumours
In reality the inputs are complex
Limited poor quality evidence base
Expert opinion
Medico-legal case law
Patient-doctor characteristics and
approach to uncertainty
Organisational factors
Red Flags
Probability of significant morbidity or mortality >1%.
Need urgent investigation
 Abnormal neurological symptoms or signs
 New seizure
 History of cancer elsewhere
Orange Flags
Headache presentations where probability is likely
to be 0.1% and 1%. Need careful monitoring and
low threshold for imaging
 Aggregated by Valsalva manoeuvre
 Headache with significant change in character
 Awakes from sleep
 New headache over 50 years
 Memory loss
 Personality change
The delivery of headache
services
Secondary Care
“The role of the specialist is to reduce uncertainty,
to explore possibility and to marginalise error.
Primary Care
“The role of the GP is to accept uncertainly, to
explore probability and to marginalise danger”.
GPs with special interest
 NHS plan calls for GPSIs to provide local,
efficient care
 Controversy over concept from primary care
 Limited evidence base
 Substitution, complementation, meeting unmet
need
Commissioning headache service
delivery
BASH 2001, ABN 2010
 GPs first line management
 GPSI support
 Tertiary headache centres
CASE 7
Jane is a 28 yr old
Presents with a visual disturbance
lasting 30 minutes. No other symptoms
What are the key questions?
What is the differential diagnosis
Secondary Headaches
AURA
Thalamus +
Mid Brain structures
Medication
overuse
headache
Tension type
headache
Hypothalamus
CLUSTER
CERVICAL
NUCLEI
MIGRAINE
CENTRE
Headache model
Primary
Headaches
CASE 7a
Jane develops a pattern of visual
disturbance followed by headache
What features would confirm a
diagnosis of migraine?
How would you manage the acute
attack?
Migraine
Prodrome 60%
Aura 30 %
Headache (30% bilateral)
Postdrome
Formal Migraine
 At least 5 attacks
 4-72 hours (1-72 hours)
 Two of : unilateral, pulsating, moderate or
severe pain, aggregation by physical activity.
(bilateral)
 At least one of: nausea/vomiting,
photophobia, phonophobia. (Can be inferred)
 Not attributed to another disorder.
In practice
Recurrent headache that bothers
Nausea with headache
Light bothers
Implications for gastric stasis and neck pain
Migraine
Acute treatment
Paracetamol, Aspirin, Domperidone.
Triptan
Triptans
Sumatriptan 100mg
Sumatriptan 50mg
Rizatriptan 10mg
Zolmitriptan 2.5mg
Eletriptan 20mg/40mg
Almotriptan 12.5mg
Naratriptan 2.5mg
Frovatriptan
Triptan Half Life
Triptans – some practical
points
Treat early
Failure not class effect
Not in CVD
SSRIs
Over 65 years
CASE 7b
Jane’s headaches become more
frequent. When would you instigate
prevention?
What is your first choice?
Migraine treatment
Preventative
 When to instigate?
 What to use?
 How long for to assess an effect?
 What rate dose increase?
 How long on preventative medication?
Migraine prevention +- evidence and licence
•
•
•
•
•
•
•
•
•
•
Beta blocker
Pizotifen
Amitriptyline
Gabapentin
Sodium valproate
Topiramate
Calcium antagonists
Lisinopril, Montelukast
Clonidine
Methylsergide
++ (L)
+ - (L)
+
+
++
+++ (L)
++--++(L)
CASE 7c
Jane has come for contraceptive
advice.
What options does she have?
What about the pill?
Ischaemic stroke
Fit women - 5/100,000 women years
Without aura - 15/100,000 women years
With aura - 30/100,000 women years
Avoid if other risk factors Eg smoking
?POP - probably safe
CASE 7d
After a few years, the migraines have
settled to monthly and associated with
menstruation only. She is fed up with
taking regular prevention.
How will you manage this?
Oestrogen sensitive migraine
Menstrual (pure - 7%, and other times
35%)
Peri-menopausal
Menstrual Migraine
 Tricycle OC
Regular NSAI
100 mcg oestrogen patch
 Regular long acting Triptan
Peri-menopausal migraine
Too much oestrogen too quickly - worse
25 mcg Evoral patch in quarters
Avoid oral oestrogen
Reassure will get better
CASE 8
Jane brings in her 13 year old son who is
getting trouble with headache. In view of
the family history you suspect migraine.
How do features in children differ from
adults?
Would you image?
What treatment would you instigate?
Headache
A complex biopsychosocial interaction
Primary Headache Epidemiology
 Headache most frequent neurological problem in
children and commonest manifestation of pain
 50% Childhood migraine becomes chronic and
continues into adulthood

 <10% will see their GP
Primary Headache Epidemiology
 10.6% migraine prevalence (3.4% age 5)
 10% -24% tension type prevalence
 0.01% cluster prevalence
 Invariably mixed or not well defined
Why don’t children seek help?
Mortimer 1992
 Don’t realise its migraine
 Only a headache
 Parents don’t want to reinforce illness
behaviour
 Parents pattern their health seeking
behaviour
What is happening in primary care?
Kernick Cephalalgia 2009
 GPs made diagnosis in 20%
 25% referred to secondary care
 3 in 10,000 tumour
 No tumours if migraine diagnosed
Diagnosis
Depression
Total in
cases
1.5%
Total in
controls
0.67%
LR
(confidence
intervals)
2.2
(1.9,2.5)
Depression in year after headache presentation
Problems with Children under
3 years
Unable to articulate symptoms of raised
intracranial pressure
Problem may be suggested by their behaviour in
ways that may be relatively subtle
Features childhood migraine
Pain is shorter acting
More likely to be bilateral
Often “mixed”
Associated with other systemic
presentations
Presentation of Brain Tumour
 40% headache (<10% headache alone)
 28% nausea and vomiting
 22% motor abnormalities
 17% visual abnormalities
 17% cranial nerve abnormalities
 10% seizures
 3% behavioural change
Wilme 2010
Red Flags
Discuss with Paediatrician the same day
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Abnormal neurological sign
Confusion or disorientation
Visual abnormalities
Abnormal head position (double vision or neck pain)
Cerebella dysfunction
Persistent headache for 4 or more weeks at presentation that
awake from sleep or occur on waking
 Persistent headache at any time in a child younger than 4 years
 Persistent headache for 2 or more weeks with vomiting
Orange Flag presentations
Need referral/close monitoring
 Headache with behavioural change
 Headache with deterioration in school work
 Headache with growth arrest or abnormal
puberty
 A persistent unilateral or occipital headache
 A persistent headache in a child with a
personal or family history of childhood tumour
 Recent change in headache characteristics in
a previous diagnosed primary headache
Management
 Avoidence of triggers
 Analgesia +-Domperidone
 Sumatriptan nasal
 Pizotifen
 Propranolol
 Amitrip
 Topiramate
School Policy Guidelines.
RCGP, Headache UK, RCN
Diagnosing the right headache
Three Key Questions
1 - What is the impact?
 Migraine - lie down
 Tension Type Headache - keep going
 Cluster Headache - bang head against wall
Diagnosing the right headache
Three Key Questions
2 - How many types of headache do you
recognise?
Diagnosing the right headache
Three Key Questions
3 - What pain killers are you taking?