Steve Elliot GPwSI Headache. History taking in episodic headache History taking in chronic headache...
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Transcript of Steve Elliot GPwSI Headache. History taking in episodic headache History taking in chronic headache...
![Page 1: Steve Elliot GPwSI Headache. History taking in episodic headache History taking in chronic headache 3minute neurological examination Who to refer.](https://reader030.fdocuments.net/reader030/viewer/2022032600/56649dca5503460f94ac0862/html5/thumbnails/1.jpg)
Steve ElliotGPwSI Headache
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History taking in episodic headache
History taking in chronic headache
3minute neurological examinationWho to refer for scanning(Management of headache)
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“Listen to the patient. He is telling you the diagnosis”
Sir William Osler (1849-1919)
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“The headache history has to be taken, not received”
Professor Peter Goadsby
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Why does it matter?Headache is not a diagnosisClear diagnostic criteriaDiagnosis before treatmentDisease specific treatments
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Guatama Buddha 563-483 BCHow to relieve suffering
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8 questions - the way to end suffering in headacheLocation?Character?Severity?Aggravation by movement?Nausea/vomiting?Photophobia?Phonophobia?Duration?
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IHS tension headache2 ofBilateralPressing./tightening/non pulsating qualityMild to moderate intensityNot aggravated by movementNo more than 1 ofNausea/vomitingPhonphobia or photophobiaDuration 30minutes to 7days
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IHS migraineNeed 2 out of:UnilateralModerate-severeThrobbingWorse with movementNeed 1 ofNausea and/or vomitingPhotophobia and phonophobiaDuration 4-72 hours
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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”
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Cluster headacheSide locked unilateralPeircing /drilling/grindingVery severeNot worse with movementPossibly nausea/vomitingPossibly unilateral photophobiaPossible phonophobia15-180 minutes durationAutonomic symptomsRestless
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Landmark study1203 patientsGP diagnosis of primary headacheHeadache diary for 3monthsDiaries analysed by blinded assessorsFindings:94% migraine or probable migraine82% “tension type headache” had migraine
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“Brain attack”Trigger – Dorsal ponsProdrome - HypothalmusAura – Cerebral cortexPeripheral sensitisation – Cranial vasculatureCentral sensitisation – ThalamusNausea/vomiting- Area Postrema Autonomic symptoms – Parasympathetic
systemNeck pain – Sensitisation of C2/C3
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Why me?Blame your parentsChemical imbalanceYour brain is differentSymptoms between attacks
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Chronic headache2-3% of population have headache on
more days than don’tHalf of above have medication overuse2%/year migraine transforms to chronicMost preceded by episodic headacheCo-mordidities anxiety,depression,obesityDifficult to manage
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Causes chronic daily headachePrimary headachesChronic tension type headacheChronic migraineChronic cluster headacheMedication overuse headacheNew daily persistent headacheHemicrania continua
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History in chronic headachePattern
Low grade all time?Low grade with exacerbations?Short lasting frequent?
Stable or progressive?8 questionsMedication including OTC?Caffeine consumption?Exclude red flags
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What not to missIdiopathic intracranial hypertensionLow pressure headache Giant cell arteritisOther secondary headache
REMEMBERHigh pressure headache WORSE on lying flatLow pressure headache BETTER lying flat
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Don’t forgetBPPalpate temporal arteries >50ESR/CRP >50DOCUMENT WHAT YOU DO
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Acute medication in migraineParacetamolAspirin 900mgNaproxen 500mgDomperidone if nauseaConsider suppositoriesAlmotriptan 12.5mg Other triptan if Almotriptan ineffectiveZolmitriptan nasal spraySumatriptan injection
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ProphylaxisPropranolol 80-240mgAmitriptyline 10-100mgPizotifen if youngTopiramate or EpilimTake 6-8 weeks to kick inSee regularly
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Don'ts in migraine treatmentOver the counterOpioidsCaffeineMigraleaveAnalgesia more than 2-3 days per
week
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Sir William Osler again“One of the first duties of the
physicians to educate the masses not to take medicines”
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Medication overuse headacheHeadache >15 day per monthIntake of following for 3months
Simple analgesia >15 days per monthOr Opioids/triptans/combination analgesia >10
days per month
Headache resolves or returns to previous pattern within 2months of discontinuation of analgesia
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What do you do when you get a headache?Stay still =MigrainePace up and down = ClusterTake tablet = Medication overuse
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Management of chronic headacheExclude red flagsEstablish phenotypeLifestyle measuresAvoid caffeine Stop analgesia(Occasional Naproxen)Start prophylaxis according to phenotypeRegular follow up
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“ The very first step towards success in any occupation is to become interested in it”
Sir William Osler (1849-1919)Canadian Physician
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