Headaches GPVTS Teaching Narcis Rugina 27 June 2012

HeadachesHeadaches

GPVTS TeachingGPVTS TeachingNarcis RuginaNarcis Rugina

27 June 201227 June 2012

IntroIntro

80 % of people in the UK affected at some time in their lives80 % of people in the UK affected at some time in their lives One of the most frequent causes of consultation in general practice One of the most frequent causes of consultation in general practice

and neurological clinicsand neurological clinics Migraines – 15% of the UK adult population (women:men=3:1)Migraines – 15% of the UK adult population (women:men=3:1)1 1

- 100,000 people absent from work/school- 100,000 people absent from work/school11

(£1.5 billion/annum cost to the economy)(£1.5 billion/annum cost to the economy) There is evidence that headache disorders are under-diagnosed and There is evidence that headache disorders are under-diagnosed and

under-treated in the UKunder-treated in the UK22

International classification of headache disordersInternational classification of headache disorders

PrimaryPrimary

1.1. MigraineMigraine, including:, including: 1.1 Migraine without aura1.1 Migraine without aura 1.2 Migraine with aura1.2 Migraine with aura

2.2. Tension-type headacheTension-type headache, including:, including: 2.1 Infrequent episodic tension-type headache 2.1 Infrequent episodic tension-type headache 2.2 Frequent episodic tension-type headache 2.2 Frequent episodic tension-type headache 2.3 Chronic tension-type headache2.3 Chronic tension-type headache

3.3. Cluster headacheCluster headache and other trigeminal autonomic cephalalgias, including: and other trigeminal autonomic cephalalgias, including: 3.1 Cluster headache3.1 Cluster headache

4.4. Other primary headaches Other primary headaches

International classification of headache disordersInternational classification of headache disorders(cont)(cont)

Secondary Secondary

5.5. Headache attributed to head and/or neck Headache attributed to head and/or neck traumatrauma, including: Chronic post-, including: Chronic post-traumatic headachetraumatic headache

6.6. Headache attributed to cranial or cervical Headache attributed to cranial or cervical vascular disordervascular disorder, including:headache , including:headache attributed to subarachnoid haemorrhage and headache attributed to giant cell attributed to subarachnoid haemorrhage and headache attributed to giant cell arteritisarteritis

7.7. Headache attributed to Headache attributed to non-vascular intracranial disordernon-vascular intracranial disorder, including: headache , including: headache attributed to idiopathic intracranial hypertension and headache attributed to attributed to idiopathic intracranial hypertension and headache attributed to intracranial neoplasmintracranial neoplasm

8.8. Headache attributed to a Headache attributed to a substance or its withdrawalsubstance or its withdrawal, including: Carbon , including: Carbon monoxide-induced headache, Alcohol-induced headache, monoxide-induced headache, Alcohol-induced headache, Medication-overuse Medication-overuse headacheheadache, Ergotamine-overuse headache, Triptan-overuse headache and , Ergotamine-overuse headache, Triptan-overuse headache and Analgesic-overuse headacheAnalgesic-overuse headache

International classification of headache disordersInternational classification of headache disorders(cont)(cont)

9.9. Headache attributed to Headache attributed to infectioninfection, including: Headache attributed to , including: Headache attributed to intracranial infectionintracranial infection

10.10. Headache attributed to Headache attributed to disorder of homoeostasisdisorder of homoeostasis

11.11. Headache or facial pain attributed to Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structuresnose, sinuses, teeth, mouth or other facial or cranial structures, , including:11.2.1 Cervicogenic headache; 11.3.1 Headache attributed to acute including:11.2.1 Cervicogenic headache; 11.3.1 Headache attributed to acute glaucomaglaucoma

12.12. Headache attributed to Headache attributed to psychiatric disorderpsychiatric disorder

Neuralgias and other headachesNeuralgias and other headaches

13. 13. Cranial neuralgias, including 13.1 Trigeminal neuralgiaCranial neuralgias, including 13.1 Trigeminal neuralgia

14. 14. Other headaches, central or primary facial painOther headaches, central or primary facial pain

Diagnosing headachesDiagnosing headaches

1. 1. Taking good historyTaking good history

- why consulting you now ?- why consulting you now ?

- onset, frequency, temporal pattern, how long lasting;- onset, frequency, temporal pattern, how long lasting;

- intensity, nature/quality of pain, site and spread, associated sptms;- intensity, nature/quality of pain, site and spread, associated sptms;

- predisposing/trigger factors, aggravating/relieving factors, ?family hx;- predisposing/trigger factors, aggravating/relieving factors, ?family hx;

- what does the patient - what does the patient do do during the headache ? (is activity during the headache ? (is activity limited/prevented ?);limited/prevented ?);

- what medication has been used and in what manner ?;- what medication has been used and in what manner ?;

- between attacks: completely well ?, residual sptms ?- between attacks: completely well ?, residual sptms ?

Diagnosing headaches (cont)Diagnosing headaches (cont)

Warning features:Warning features:

- new or unexpected;- new or unexpected;

- thunderclap- thunderclap

- aura>1hr or including motor weakness;- aura>1hr or including motor weakness;

- aura first time in a patient using COC;- aura first time in a patient using COC;

- new onset if >50yo;- new onset if >50yo;

- new onset if <10yo;- new onset if <10yo;

- persistent morning headaches with nausea;- persistent morning headaches with nausea;

- associated with postural change;- associated with postural change;

- new onset in a patient with cancer/HIV.- new onset in a patient with cancer/HIV.

Physical examinationPhysical examination

- Brief (but comprehensive) neurological examination: Romberg, walk on toes/heels, - Brief (but comprehensive) neurological examination: Romberg, walk on toes/heels, outstretched arms, finger-nose, finger-hand, visual fields, eye movements, face (all of the outstretched arms, finger-nose, finger-hand, visual fields, eye movements, face (all of the above can be done in 60 seconds !) + reflexes, plantars, fundoscopy. (above can be done in 60 seconds !) + reflexes, plantars, fundoscopy. (http://www.youtube.com/watch?v=fgwN1P5DaA) )

- BP measurement (it is said that raised BP do not cause headache, patients believe - BP measurement (it is said that raised BP do not cause headache, patients believe otherwise);otherwise);

- examination of head and neck for muscle tenderness, stiffness, limitation of ROM, - examination of head and neck for muscle tenderness, stiffness, limitation of ROM, crepitation – often revealing, especially in TTH;crepitation – often revealing, especially in TTH;

Performing all of the above repays the time spent through its therapeutic value.Performing all of the above repays the time spent through its therapeutic value.

Only 0.9% of headaches without neurological signs have significant pathologyOnly 0.9% of headaches without neurological signs have significant pathology3 3 ..

http://www.youtube.com/watch?v=fgwN1P5DaA

ImagingImaging

Only if secondary causes suspected.Only if secondary causes suspected. Therapeutic value/anxiolytic effect of a normal brain scan not sustained beyond a few Therapeutic value/anxiolytic effect of a normal brain scan not sustained beyond a few

monthsmonths44.. Cervical spine Xray – usually do not alter management.Cervical spine Xray – usually do not alter management.

Serious causesSerious causes MeningitisMeningitis Subarachnoid haemorrhageSubarachnoid haemorrhage Intracranial tumourIntracranial tumour Giant cell arteritsGiant cell arterits Primary angle-closure glaucomaPrimary angle-closure glaucoma Idiopathic intracranial hypertensionIdiopathic intracranial hypertension Carbon monoxide poisoning (stereotype exam question: student comes with Carbon monoxide poisoning (stereotype exam question: student comes with

headache, lethargy, nausea)headache, lethargy, nausea)

IHS diagnostic criteriaIHS diagnostic criteria for Migrainefor Migraine withoutwithout aura aura

A. A. At least 5 attacks fulfilling criteria B-DAt least 5 attacks fulfilling criteria B-D B. B. Attacks lasting 4-72hrs (shorter in children, common bilateral, GI sptms prominent)Attacks lasting 4-72hrs (shorter in children, common bilateral, GI sptms prominent) C.C. At least two of the following: At least two of the following:

1. Unilateral1. Unilateral

2. Pulsating2. Pulsating

3. Moderate or severe3. Moderate or severe

4. Aggravated by or causing avoidance of routine physical activity (ie walking)4. Aggravated by or causing avoidance of routine physical activity (ie walking) D. D. At least one of the following:At least one of the following:

1. nausea and/or vomiting1. nausea and/or vomiting

2. photophobia and phonophobia2. photophobia and phonophobia E. E. Not attributed to another disorderNot attributed to another disorder

IHS diagnostic criteria for Migraine IHS diagnostic criteria for Migraine withwith aura aura

A. At least two attacks fulfilling three or more of the following: 1. One or more fully reversible aura symptoms indicating focal cerebral cortical

and/or brain stem functions. 2. At least one aura symptom develops gradually over more than four minutes, or two

or more symptoms occur in succession. 3. No aura symptom lasts more than 60min; if more than one aura symptom is

present, accepted duration is proportionally increased. 4. Headache follows aura with free interval of at least 60min (it may also

simultaneously begin with the aura.

B. At least one of the following aura features establishes a diagnosis of migraine with typical aura:

1. Homonymous visual disturbance. 2. Unilateral paresthesias and/or numbness. 3. Unilateral weakness. 4. Aphasia or unclassifiable speech difficulty.

Migraine - treatmentMigraine - treatment

Use treatment ladder; go to next step if failure on three occasions with previous step Use treatment ladder; go to next step if failure on three occasions with previous step medication.medication.

Step Step 11: a) Aspirin 600-900mg-qds or Ibuprofen 400-600mg-qds : a) Aspirin 600-900mg-qds or Ibuprofen 400-600mg-qds

((Little evidence for the efficacy of Paracetamol aloneLittle evidence for the efficacy of Paracetamol alone5050 !) !)

+/- Antiemetics: Prochlorperazine 3-6mg buccal tablet (max twice in 24hrs)+/- Antiemetics: Prochlorperazine 3-6mg buccal tablet (max twice in 24hrs)51 51

or Domperidone 10mg qdsor Domperidone 10mg qds

b) Naproxen 750-825mg statb) Naproxen 750-825mg stat53,54,55 53,54,55 with further 250-275mg up to twice in 24hrs with further 250-275mg up to twice in 24hrs or Diclofenac-potassium 50-100mgor Diclofenac-potassium 50-100mg56,57,5856,57,58 repeated up to 200mg/24hrs repeated up to 200mg/24hrs

+ Prokinetic antiemetics: Metoclopramide 10mg or Domperidone 20mg+ Prokinetic antiemetics: Metoclopramide 10mg or Domperidone 20mg61 61

Combinations: MigraMax (lysine acetylsalicylate 1620mg-equiv of Aspirin 900mg + Combinations: MigraMax (lysine acetylsalicylate 1620mg-equiv of Aspirin 900mg + Metoclopramide 10mg) tds; Paramax sachets (Paracetamol 500mg + Metoclopramide Metoclopramide 10mg) tds; Paramax sachets (Paracetamol 500mg + Metoclopramide 5mg), 2 sachets tds.5mg), 2 sachets tds.

Migraine – treatment (cont)Migraine – treatment (cont)

Step Step 22: : Rectal analgesic +/- antiemeticRectal analgesic +/- antiemetic

- Diclofenac supp 100mg, bd +/- Domperidone supp 30-60mg, up to - Diclofenac supp 100mg, bd +/- Domperidone supp 30-60mg, up to 120mg/24hrs.120mg/24hrs.

Step Step 33 : : Specific anti-migraine drugsSpecific anti-migraine drugs

- 30% fail to respond- 30% fail to respond

- if poor response to one triptan, - if poor response to one triptan, can can benefit from another in subsequent attacksbenefit from another in subsequent attacks

- Triptans - Triptans must must be taken at the start of the headache phasebe taken at the start of the headache phase6969 , NOT during , NOT during auraaura70,71 70,71

Examples: Examples:

- Sumatriptan, 50mg tablet or rapidly-dispersing RADIS 50mg tablet; if inadequate response, - Sumatriptan, 50mg tablet or rapidly-dispersing RADIS 50mg tablet; if inadequate response, 100mg or 20mg (10mg for 12-17yo) nasal spray can be used (max 300mg PO or 40mg 100mg or 20mg (10mg for 12-17yo) nasal spray can be used (max 300mg PO or 40mg intranasally). For intranasally). For rapid rapid response – 6mg subcut (max 12mg/24hrs).response – 6mg subcut (max 12mg/24hrs).


- Zolmitriptan 2.5mg (RAPIMELT-orodispersible) - second dose can be taken in 2 Zolmitriptan 2.5mg (RAPIMELT-orodispersible) - second dose can be taken in 2 hours; for recurrences – 5mg initially (max 10mg/24hrs); Nasal spray 5mg.hours; for recurrences – 5mg initially (max 10mg/24hrs); Nasal spray 5mg.

- Rizatriptan 10mg (max 20mg/24hrs)Rizatriptan 10mg (max 20mg/24hrs)

Contraindications to step 3: uncontrolled HTN, risk factors for coronary heart disease and Contraindications to step 3: uncontrolled HTN, risk factors for coronary heart disease and children under 12yo.children under 12yo.

- Step Step 44 : : CombinationsCombinations

- - Sumatriptan 50mg + Naproxen 500mg superior to either drug aloneSumatriptan 50mg + Naproxen 500mg superior to either drug alone95 95

- steps (1 + 3) followed by steps (2 + 3)- steps (1 + 3) followed by steps (2 + 3)


RelapsesRelapses: Naratriptan, Eletriptan and Frovatriptan – low recurrence rates: Naratriptan, Eletriptan and Frovatriptan – low recurrence rates104104.. Ergotamine 1-2mg, significantly lower recurrence rateErgotamine 1-2mg, significantly lower recurrence rate9393, better as suppositories, , better as suppositories,

max 4mg/24hrs; not to be taken max 4mg/24hrs; not to be taken concomitantly concomitantly with any triptan.with any triptan.

ProphylaxisProphylaxis: 6-8/52 titration doses, if effective – continue 4-6/12.: 6-8/52 titration doses, if effective – continue 4-6/12. -1-1stst line: -Beta-blockers line: -Beta-blockers110,111110,111 (CI - asthma, heart failure, PVD, (CI - asthma, heart failure, PVD, depression) – Atenolol (25-100mg BD), Metoprolol depression) – Atenolol (25-100mg BD), Metoprolol (50-100mg BD), Propranolol (80mgOD-160mgBD).(50-100mg BD), Propranolol (80mgOD-160mgBD).N.B.N.B. No evidence for effectiveness in Chronic Migraine !No evidence for effectiveness in Chronic Migraine ! -Amitriptyline (10-150mg), Nortriptyline, Dothiepin, if associated with -Amitriptyline (10-150mg), Nortriptyline, Dothiepin, if associated with

disturbed sleep, disturbed sleep, TTH, depression, another chronic pain condition.TTH, depression, another chronic pain condition.

-2-2ndnd line: Topiramate (25mg OD – 50mg BD line: Topiramate (25mg OD – 50mg BD)113,114,115,)113,114,115, Sodium valproate (300 – 1000mg BD)Sodium valproate (300 – 1000mg BD)116,119116,119


Prophylaxis: Prophylaxis:

-3-3rdrd line: Gabapentin (300mg OD – 800mg TDS), little evidence line: Gabapentin (300mg OD – 800mg TDS), little evidence121121

Methysergide (1-2mg TDS)Methysergide (1-2mg TDS)122 122

Synergistic effect of combining B-blocker + Amitriptyline (no Synergistic effect of combining B-blocker + Amitriptyline (no

formal evidence)formal evidence)

Limited efficacy: PizotifenLimited efficacy: Pizotifen123123, Clonidine, Clonidine124124, Verapamil., Verapamil.

Menstrual attacks of migraine: Frovatriptan for 6days (5mg BD on day 1,Menstrual attacks of migraine: Frovatriptan for 6days (5mg BD on day 1,

2.5mg BD on days 2-6) starting 2 days before the expected onset of 2.5mg BD on days 2-6) starting 2 days before the expected onset of

migrainemigraine139,140139,140. Also, transdermal estrogen 100mcg, a 7day patch, 3days. Also, transdermal estrogen 100mcg, a 7day patch, 3days

before the onset of menses; Estradiol gel (1.5mg in 2.5g gel).before the onset of menses; Estradiol gel (1.5mg in 2.5g gel).

HRT in women with migraine – no contraindication.HRT in women with migraine – no contraindication.

Migraine – treatment (cont)… Migraine – treatment (cont)… and the lastand the last

Non-drug interventionNon-drug intervention

- physical therapy- physical therapy163163, acupuncture, acupuncture164 164 , psychological therapy , psychological therapy

(relaxation therapy, stress reduction and coping strategies,(relaxation therapy, stress reduction and coping strategies,

yoga and meditation);yoga and meditation);

- homeopathy – no value- homeopathy – no value165,166,167165,166,167

- hypnotherapy – unproven value- hypnotherapy – unproven value

- reflexology – no scientific basis- reflexology – no scientific basis

Tension-type headache (TTH)Tension-type headache (TTH)

A) First measures:A) First measures:

- regular exercise, physiotherapy (massage, mobilisation, - regular exercise, physiotherapy (massage, mobilisation,

manipulation, correction of posture);manipulation, correction of posture);

- when stress-related: life-style changes, relaxation therapy, - when stress-related: life-style changes, relaxation therapy,

cognitive training to develop stress-coping strategies.cognitive training to develop stress-coping strategies. B) Drug therapy:B) Drug therapy:

- Aspirin 600-900mg, Ibuprofen 400mg, Ketoprofen 25-50mg,- Aspirin 600-900mg, Ibuprofen 400mg, Ketoprofen 25-50mg,

Naproxen 250-500mgNaproxen 250-500mg

- - Paracetamol – less effectiveParacetamol – less effective175175 ! !

-Avoid Codeine, Dihydrocodeine, opiates.-Avoid Codeine, Dihydrocodeine, opiates.

- - Frequent, unremitting TTH ? Give 3/52 course of Naproxen Frequent, unremitting TTH ? Give 3/52 course of Naproxen

250-500mg BD 250-500mg BD maymay break the cycle. break the cycle.

Treatment of choiceTreatment of choice remains Amitriptyline, titrating from 10-25mg with remains Amitriptyline, titrating from 10-25mg with

increments of 10-25mg every 1-2/52, up to 150mg at night.increments of 10-25mg every 1-2/52, up to 150mg at night.

Tension-type headache (TTH)Tension-type headache (TTH)

Often refractory.Often refractory. Association with personality factors of psychosocial dysfunction – suspected but not Association with personality factors of psychosocial dysfunction – suspected but not

consistently demonstrated.consistently demonstrated. Cognitive therapies, TENS may be offered.Cognitive therapies, TENS may be offered. Acupuncture – unproven but worth tryingAcupuncture – unproven but worth trying180180.. Homoeopathy – unknown value.Homoeopathy – unknown value.

Cluster headache (CH)Cluster headache (CH)

Better left to experienced specialists who see this disorder frequently.Better left to experienced specialists who see this disorder frequently. Poor understanding of underlying mechanism.Poor understanding of underlying mechanism. Prophylaxis – mainstay of treatment:Prophylaxis – mainstay of treatment:

- Verapamil 80mg tds or qds (up to 960mg daily - Verapamil 80mg tds or qds (up to 960mg daily required). Check ECG before dosage reaches 480mg and whenever is increased after required). Check ECG before dosage reaches 480mg and whenever is increased after that. No concomitant beta blocker use.that. No concomitant beta blocker use.

- Prednisolone- Prednisolone186186 60-100mg daily for 2-5 days 60-100mg daily for 2-5 days

- Lithium- Lithium

- Methysergide 1-2mg tds may be effective in 70%, - Methysergide 1-2mg tds may be effective in 70%, worth trying when other treatments fail.worth trying when other treatments fail.

- Ergotamine 1-2mg suppository at night- Ergotamine 1-2mg suppository at night

Acute treatment: Sumatriptan 6mg subcutAcute treatment: Sumatriptan 6mg subcut195,196 195,196 ; Oxygen 100% at 10-15l/min, ; Oxygen 100% at 10-15l/min,

10-20 min helps 10-20 min helps some some people-unlicensed.people-unlicensed.

Medication-overuse headache (MOH)Medication-overuse headache (MOH)

According to ICHD-II (2004):According to ICHD-II (2004):

Simple analgesics (taken >15 days/month for >3 months), as well as combination Simple analgesics (taken >15 days/month for >3 months), as well as combination analgesics, opioids, ergots, and triptans (taken at least 10 days/month for >3 months), analgesics, opioids, ergots, and triptans (taken at least 10 days/month for >3 months), can lead to this phenomenon.can lead to this phenomenon.

MOH includes the following features: MOH includes the following features: 1) headache frequency increases over time; 1) headache frequency increases over time; 2) patients often awaken early with headache (despite this not being a feature of original2) patients often awaken early with headache (despite this not being a feature of original

headache);headache);

3) a proportion of attacks may become nondescript, losing migrainous3) a proportion of attacks may become nondescript, losing migrainous or autonomic or autonomic

features, and begin resembling tension-type headache; features, and begin resembling tension-type headache; 4) a lowered threshold for stress or exertion to precipitate headaches is present; 4) a lowered threshold for stress or exertion to precipitate headaches is present; 5) escalating doses of analgesics are required; and 5) escalating doses of analgesics are required; and 6) headaches occur within predictable time frame after analgesic consumption, with 6) headaches occur within predictable time frame after analgesic consumption, with

reduced efficacy. reduced efficacy.


Management:Management:

- outpatient medication withdrawal (exclusion criteria – severe nausea, vomiting, - outpatient medication withdrawal (exclusion criteria – severe nausea, vomiting, dehydration, use of strong opiates, barbiturates, tranquilisers, uncontrolled HTN);dehydration, use of strong opiates, barbiturates, tranquilisers, uncontrolled HTN);

- the most important approach is the explanation of the rationale and purpose of - the most important approach is the explanation of the rationale and purpose of medication withdrawal (medication withdrawal (PET scans showed hypometabolism in brain areas known to be PET scans showed hypometabolism in brain areas known to be involved in pain processing; in 3/52 these changes resolve after meds withdrawalinvolved in pain processing; in 3/52 these changes resolve after meds withdrawal197197))

- warn patients that they may experience a transient worsening of their headaches- warn patients that they may experience a transient worsening of their headaches

- arrange review;- arrange review;

- if analgesics are re-introduced, no more than 2 days/week !- if analgesics are re-introduced, no more than 2 days/week !


Management (2):Management (2):

- allow NSAIDS as rescue medication – Naproxen 500-1000mg/day; Can be used as - allow NSAIDS as rescue medication – Naproxen 500-1000mg/day; Can be used as preventative medication to break cycle – 250mg TDS for 2/52, then BD for another 2/52 preventative medication to break cycle – 250mg TDS for 2/52, then BD for another 2/52 and OD for last 2/52and OD for last 2/52

- introduce a prophylactic medication - introduce a prophylactic medication immediately (immediately (Amitriptyline, sodium valproate, Amitriptyline, sodium valproate,

topiramate)topiramate)

- greater occipital nerve infiltration with lidocaine and depo-medrone, particularly where - greater occipital nerve infiltration with lidocaine and depo-medrone, particularly where point tendernes of the nerve accompanies chronic ipsilateral head pain;point tendernes of the nerve accompanies chronic ipsilateral head pain;

- last resort, admission, iv Aspirin 1gtds, iv sodium valproate up to 2g /day, or iv - last resort, admission, iv Aspirin 1gtds, iv sodium valproate up to 2g /day, or iv dihydroergotamine 1mg tdsdihydroergotamine 1mg tds

- Relapse rate high - 1/3 -1/2; - Relapse rate high - 1/3 -1/2;


Management (3):Management (3):

- However, 81% had a decreased severity or frequency of - However, 81% had a decreased severity or frequency of at least 50 percentat least 50 percent after two after two months, and 61% maintained this at 1 and 4 years follow upmonths, and 61% maintained this at 1 and 4 years follow up198198..

Also…Also…

Chronic daily headacheChronic daily headache: :

- Chronic migraine - - Chronic migraine - at least a 3-month history of headaches occurring >15 at least a 3-month history of headaches occurring >15 days/month, meeting criteria for migraine on >8 days/month, in the absence of days/month, meeting criteria for migraine on >8 days/month, in the absence of

medication overusemedication overuse - - Chronic TTH, Chronic TTH, - Hemicrania continua and - Hemicrania continua and - New daily persistent headache (NPDH) - - New daily persistent headache (NPDH) - acute constant unremitting headache, acute constant unremitting headache,

developing over less than 3 days. Patients often pinpoint the exact calendar date, often developing over less than 3 days. Patients often pinpoint the exact calendar date, often the exact hour, of headache onset. In NPDH, a search for secondary causes is the exact hour, of headache onset. In NPDH, a search for secondary causes is mandatory, given treatment attempts for NDPH are often less successful. mandatory, given treatment attempts for NDPH are often less successful.

- - Medication overuse headacheMedication overuse headache

- - Chronic post-traumatic headacheChronic post-traumatic headache

Patient satisfaction

Hospital Clinic attenders = 72%

GPwSI Clinic attenders = 79%199

(in terms of waiting time, ease of access, being listened to and understood, the help they had received, the extent to which their needs were met, symptoms relief, ability to deal more effectively with their problems)

BibliographyBibliography

BASH (British Association for the Study of Headache), 3BASH (British Association for the Study of Headache), 3 rdrd edition, 2010 (and its edition, 2010 (and its bibliography list).bibliography list).

1. Steiner TJ, Lipton R. The prevalence and disability burden of adult migraine in 1. Steiner TJ, Lipton R. The prevalence and disability burden of adult migraine in Enhland. Cephalgia 2003; 23: 519-527.Enhland. Cephalgia 2003; 23: 519-527.

2. American association for the study of headache, International Headache Society. 2. American association for the study of headache, International Headache Society. Consensus statement on improving migraine management. Headache 1998; 38: 736.Consensus statement on improving migraine management. Headache 1998; 38: 736.

3. Sempere A, Porta-Etessam J. Neuroimaging in the evaluation of patients with non-3. Sempere A, Porta-Etessam J. Neuroimaging in the evaluation of patients with non-acute headache. Cephalgia 2005; 25: 30-35.acute headache. Cephalgia 2005; 25: 30-35.

4.Howard L, Wessely S. Are investigation anxiolytic or anxiogenic ? RCT of 4.Howard L, Wessely S. Are investigation anxiolytic or anxiogenic ? RCT of neuroimagingto provide reassurance in chronic daily headache. J Neurol Neurosurg neuroimagingto provide reassurance in chronic daily headache. J Neurol Neurosurg Psychiatry 2005; 76: 1558-1564.Psychiatry 2005; 76: 1558-1564.

**********BASH**************BASH**** 197. Fumal A, Laureys S, Di Clemente L, et al. Orbitofrontal cortex involvement in 197. Fumal A, Laureys S, Di Clemente L, et al. Orbitofrontal cortex involvement in

chronic analgesic overuse headache. Brain 2006; 129:543-550.chronic analgesic overuse headache. Brain 2006; 129:543-550. 198. Freitag FG, Lake A III, Lipton R, et al. Inpatient treatment of headache: an evidence-198. Freitag FG, Lake A III, Lipton R, et al. Inpatient treatment of headache: an evidence-

baseed assessment. Headache 2004;44:342-60.baseed assessment. Headache 2004;44:342-60. 199. Ridsdale et al. BJGP, 2008.199. Ridsdale et al. BJGP, 2008.

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Headaches GPVTS Teaching Narcis Rugina 27 June 2012