Headache Management in

Primary Care
Dr Niranjanan Nirmalananthan
Consultant Neurologist
Wednesday 10th of April 2019
Summary

• Why does it matter?

• Classification and diagnosis
• Who to refer / scan?
• Serious & Common headaches
Why does it matter?
• Common
• 3% of GP consultations
• 2% of A&E attendances
• 20% of all acute neurology admissions
• Up to 25% of General Neurology OPD

• Important – Migraine alone

• WHO Top 10 causes of disability
• £250 million direct cost to NHS
• mostly primary care
• £2.25 billion absenteeism losses
• Presenteeism
What do GPs See?

• TTH 21%

• Migraine 72%

• Cluster 2%

• Secondary headaches 5%
Kernick, 2008
Headache – making a diagnosis

• History is everything

• Brief focused examination excludes serious pathology

• For most patients tests add (very) little.

• Main question is ? Primary or Secondary

Taking a headache history

• ONSET
• How “sudden” is sudden?
• “How long did it take to get to its worst“
• Duration
• How long?
• Truly constant? or variable / episodic? Frequency?
• “Crystal Clear” days?
• Severity
• Link it to duration
• Minimum / Maximum, proportion at maximum
• Quality
• Throbbing
• Aching, stabbing, etc. etc.
• Antecedent headache history
• Ever get headaches?
• Periods, Hangovers, “Hungry headaches”
• Triggers, caffeine
• Cyclical vomiting / Benign childhood vertigo / Abdominal migraine / Travel sickness
Headache history – associated features

• Migrainous features
• Photophobia / Phonophobia / Osmophobia / Kinetophobia
• Nausea / vomiting
• Aura – visual / sensory / motor / aphasia / etc.

• Pressure features
• Effect of posture
• Bending forward
• Cough / Sneeze / Strain
• Visual obscurations / Pulsatile tinnitus

• Cervical features
• pain / tenderness / reduced range of movement

• Autonomic features (? Cluster headache / TAC)

• Unilateral tearing, conjunctival injection, rhinorrhea, flushing etc.

• Drug History
• Analgesic overuse! OTC meds
• Drug-induced headache (sildenafil, nitrates, clopidogrel etc. etc.)
Focused Examination
• Systemically unwell: tachycardic, hypertensive, fever, rashes
• Obvious focal neurological signs
• Standard neurology
• Pupils
• Eye movements
• Facial sensation / movement
• Cognition
• Personality
• Nuchal rigidity ≠ Neck tenderness
• Temporal artery pulsation / tenderness
• Best palpated anterior to tragus
• Fundoscopy (Panoptic)
• Papilloedema

• ? Bloods
• ESR in over 50s
Thinking Fast and Slow - Heuristics

• Contextual information
• Longitudinal knowledge of patient
• ± patient’s family
• “The test of time”
• Most primary care headache is benign and self-limiting
• 70% of primary care headache, no diagnosis made
• Beware of first impressions lasting
• Review history if phenotype changes
• Beware of therapeutic trials for diagnosis
• Patient’s hypothesis
Headache Diary

• frequency, duration and severity

• associated symptoms
• all prescribed and OTC painkillers
• possible triggers
• relationship of headaches to
menstruation
Who should I be concerned
about?
Red Flags

• Epidemiological features
• New headache and patient > 50 yo (GCA / SOL)
• Pregnant or recent post-partum
• Obesity (IIH)
• Co-morbidity
• Known cancer
• Active immunodeficiency
• Recent (<3m) Head Trauma
• Family or past personal history of aneurysmal SAH
Red Flags
• Headache features
• Thunderclap headache
• Raised ICP features
• New daily persistent headache
• Headache on exertion
• New headache with vomiting ++
• Features of GCA / Acute Glaucoma
• Signs
• Fever, confusion, drowsiness, neck stiffness
• Any neurological signs
Secondary Headache
Disorders
Shouldn’t I have a scan doc?
• Why do they want a scan?

• Clear primary headache phenotype?

• No!
• Features of brain tumour?
• TWR
• Not sure what it is?
• Review with diary
• Refer, don’t scan
• “Just for reassurance” (patient? doctor?)
• Incidental abnormalities are common
• Reassurance doesn’t last
• Reinforces false beliefs
• Doesn’t manage symptoms
• 5 year study – 3 neurologists
• 3655 new patients with headache disorders
• 530 (14.5%) were scanned
• 46% had insignificant abnormalities on MRI
• 28% on CT.
• 11 (2.1%) had significant abnormalities.
• When the neurologist suspected an abnormality 5.5%
(1 in 20) had one.
Brain tumours

• Rare:
• 10/100,000/y

• TWR criteria:
• Subacute progressive neurological signs
(including cognition / personality)

• New seizures
• Headache with above or raised ICP
features
Brain tumours
• < 10% of brain tumours present with isolated
headache
• “featureless”
• progressive and persistent
• +/- raised ICP features
• Early morning
• Cough, sneeze, strain precipitates

• Isolated headache in primary care?

• < 0.05% probability of brain tumour
• Chronic headache? even less likely
36 year old male plumber

• Previously well. Presents to A&E.

• Complains of the worst headache of his

life. Came on suddenly. Feels sick, but
no vomiting. Wants the light off in the
cubicle. Complains his neck hurts.

• His examination is normal.

Thunderclap Headache

• Sudden onset severe headache

≠ Thunderclap headache ≠SAH

• Maximum severity within 5 minutes (and

lasts > 1 hour)
• 10-25% of true thunderclap is SAH
• <50% of SAH is isolated thunderclap
Thunderclap headache
• Differential is essentially vascular:
• SAH
• Cerebral Venous Sinus Thrombosis
• Carotid dissection
• Hypertensive encephalopathy
• Pituitary apoplexy
• Reversible Cerebral Vasoconstriction Syndrome
• Primary headache disorders
• Benign sex headache (coital cephalalgia)
• Primary cough headache
• Primary exertional headache
• Primary thunderclap headache
23 year old female student

• Feeling “grotty” for a few days

• 24 hour progressive history of headache,
nausea, neck pain.
Acute bacterial meningitis
• Headache, with photophobia, nausea and vomiting
occurs in 80-95%

• Apart from headache the key features are:

• fever
• neck stiffness
• confusion

• Only 40% have all 3 but absence of all 3 excludes

bacterial meningitis with a 99% sensitivity
23 ♀, rapid onset of headache 2 weeks
post-partum

• Headache history
• Bifrontal throbbing headache, built up in 20
minutes out of the blue
• Worse on coughing, sneezing and straining
• Headache is 8/10 severity and persistent for last 3
days
• Associated Symptoms
• Nausea, no vomiting
• Vision sometimes “dims out”
23 ♀, rapid onset of headache 2
weeks post-partum
 Papilloedema

Blurred optic
disc margin

Haemorrhages
Loss of venous pulsations

Small optic
cup

Cotton wool spots

 Cerebral Venous Sinus Thrombosis

• Headache
• Present in 90% of patients,
• often the presenting feature
• the ONLY feature in 30%
• Typically has raised pressure features
• Can present as thunderclap
• Untreated → complications (ICH, SAH, seizures, coning)

• Refer for urgent assessment and CT / MR venography

• In young, obese women with raised ICP headache and

papilloedema consider Idiopathic Intracranial
Hypertension but only after excluding CVST
65 ♀ with new onset headache

• Headache history
• Generalised vague dull headaches, not localised
• Can’t remember exact onset, “weeks”
• Persistent but seem worse at night
• No crystal clear days
• Headache is 5/10 severity
• Associated Symptoms
• Has felt generally under the weather and a bit depressed
• Noticed a decrease in appetite and some weight loss
• General weakness in the upper limbs
• Antecedent headache history
• Mild tension-type headaches in 20s.
Giant Cell Arteritis
• Headache features
• New onset headache in middle age / elderly - can be any location
• Typically continuous and interferes with sleep
• Scalp tenderness is NOT specific or particularly sensitive

• Other features
• Systemically unwell
• Jaw claudication (~50%)
• occasionally intermittent claudication in the limbs or tongue
• visual loss in ~20% (often early) if untreated
• sudden, bilateral visual loss can occur, esp. in elderly
• PMR in 50%, but muscle aches often not prominent

• Tests
• ESR, CRP and FBC
• ESR typically ≥ 50mm/h, CRP usually high, 50% anaemic

• Treat if temporal tenderness, ESR > 50, CRP > 5

• Start steroids first (60mg od) and refer
Cervicogenic headache

• Headache with neck or scalp tenderness ≠

cervicogenic headache
• Overdiagnosed
• Inappropriate referral to MSK
• Undertreatment

• Key features
• Restricted range of movement
• Provocative manoeuvres reproduce
Primary Headache
Disorders
Primary Headache disorders

• Tension-type headache
• Migraine
• Trigeminal autonomic cephalalgias
• e.g. cluster headache
• Other primary headaches are rare

• Make a positive diagnosis

Migraine – Management
• Clear, positive diagnosis and a clear plan

• Lifestyle / Triggers
• Sleep
• Caffeine
• COC advice

• Abortive treatments

• Prophylactic therapy

• Education & Self-management

• Give written information (Migraine Trust / Migraine Action)
• Explore triggers / lifestyle issues
• Headache Diary
• Psychological Co-morbidity
Improving Migraine Management

• Underdiagnosis
• Lack classic migrainous symptoms (especially in chronic migraine)
• Absence of aura
• Analgesia overuse
• Episodic disabling headache is migraine
• TTH / sinus headache very overdiagnosed

• Undermanaged
• Propagation of analgesia overuse
• Lack of patient education re: abortives
• Prophylactic use – dose / duration of Rx
Migraine - Abortive
• Analgesics: maximum 2 -3 days a week

• Treat hard, treat early

• NSAIDs
• High dose, e.g.
• 600-800 mg Ibuprofen
• 900mg Aspirin
• 500mg Naproxen
• Triptans (not if CV disease)
• Consider wafers, nasal, subcut in refractory patients
• At least 3 attacks
• Try all 7 if necessary
• Don’t use Triptan response for diagnosis
• NSAID + Triptan is more effective
• DON’T GIVE OPIATES (or recommend OTC containing opiates, e.g. Migraleve)

• Antiemetics
• For gastroparesis ± nausea
• domperidone or metoclopramide

• Severe acute migraine with:

• sc sumatriptan / im diclofenac / im metoclopramide
Migraine - Prophylaxis
• If > 8 days a month
• discuss if 4-8 days a month and major QoL impact
• Good RCT evidence for:
• Propranolol (target 160mg total, up to 240mg)
• Topiramate (target 100mg total, up to 200mg)
• Amitryptiline (target 50mg total, up to 100mg)
• Candesartan (target 16mg total, up to 32mg)
• Pizotifen (1.5-3mg total)
• Valproate (up to 2000mg total)

• High dose for minimum 2-3 months

• Analgesic overuse impacts prophylactic efficacy
• Target 50% reduction in headache severity or frequency
• Wean after ≥ 6 months of stability
• Failed 3 prophylactics? → Botox
Pure Menstrual Migraine

• Frovatriptan 2.5 mg bd or
• Naproxen 500mg bd

• From 3 days before for total 6 days

Migraine in Pregnancy
• Really bad morning sickness
• Worse in 1st TM, much better in TM2/3
• Worse after deliver / stopping breastfeeding

• Paracetamol
• NSAIDs 2nd TM only
• Triptans with caution
Cautions

• Very first episode of severe migrainous

headache
• Image it in the over 50s.
• Very rapid onset of Aura (<5 mins) and
prolonged aura (>60 mins) are
concerning
• Major change of phenotype can be a sign
of additional pathology
35 year old male Accountant
• 5 months of bad bilateral headache, constant for 4
months - there all the time. Varies from 6-9/10 in
severity. Feels sick with it, but otherwise featureless.
• Had migraines in his 20s, but very rarely since. When
headache started 5 months ago it was a bit like his old
migraine, but current headache is completely different.
• When these headaches started, they were not getting
better with paracetamol or ibuprofen and now taking
daily co-codamol from GP for the last 3 months with
some acute relief.
• Examination is normal
Medication-Overuse Headache

• HUGE PROBLEM (1-2% of population)

• Any patient, with any episodic primary headache

disorder may develop chronic daily headache if given
frequent analgesics
• 10 - 15 /m paracetamol / NSAIDs
• 8 -10 /m for triptans
• 6 – 8 /m for opiates
Medication-Overuse Headache

• Increased severity and frequency

• Background headache
• Becomes featureless
• Prophylactics won’t work!

• If you see patients with persistent headache on

analgesics
• Try “detox” –
• “short sharp shock”
• Wean opiates slowly
• Limit 2 days per week
• BAN opiates
• Start prophylaxis for underlying primary HA
Chronic Daily Headache /
Chronic Migraine

• >15 days a month of headache of any kind

• “8 days migrainous”
• Overwhelmingly, most chronic headache is chronic migraine ± medication
overuse headache

• Tips:
• Always push about analgesic frequency
• “Crystal clear days”
• Severity at worst and best?
• Number of days per week it is at its worst?
• Focus on the bad days to identify migrainous features
• Identify what the headache phenotype was like before “chronification”
Advanced Therapies
• Nerve blocks
• > 60% response in chronic headache
• Botulinum toxin therapy
• NICE approved for Chronic Migraine
• Failed 3 prophylactics
• Transcranial Magnetic Stimulation
• NICE IPG
• Implanted occipital nerve stimulation for intractable
migraine
• CGRP Monoclonal Antibodies
• NICE TA pending
Tension-type Headache
• Defined by what it isn’t
• Mild, featureless, bilateral
• Rx
• Paracetamol or NSAIDs ≤ 2 days pw
• Explore Triggers / Psychological / Environmental

• Consider prophylaxis if frequent 8-15 days a month

(risk of medication overuse headache)
• Amitryptiline, Venlafaxine, Mirtazepine
• >15 days a month – think again
• Migraine? Secondary disorder?
Cluster Headache
Cluster headache
• History:
• Occurs in clusters
• several attacks a day for weeks / months,
• then remission
• Strictly unilateral
• Excruciatingly severe, frontal / retro-orbital
• Attacks shorter than migraine
• 30 min – 4 hours
• Up to 8 times a day
• Ultradian rhythms (more often at night)
• Patients are restless (cf migraine)

• Trigeminal autonomic features

• Ptosis, tearing, conjunctival injection, flushing, rhinorrhea
Cluster headache
• Acute treatment:
• High flow O2 – aborts most attacks
• 100% via non-rebreathe mask
• Sc sumatriptan 6mg
• Nasal triptans may work (less effective)
• Oral triptans do not work

• Prevention:
• High dose prednisolone at cluster onset, tapering
• Greater Occipital Nerve Block at start of a cluster
• Start Verapamil (or Lithium / Topiramate)
Other primary headaches
• Occasional severe brief stabs?
• Primary stabbing headache

• Waking up head feels like it exploded?

Exploding head syndrome

• Short lasting, unilateral neuralgic headaches,

with conjunctival injection and tearing?
• SUNCT
Who to refer with primary headaches?

• Everyone with cluster headache and related disorders

• Refractory high frequency episodic migraine
• Failed on 2-3 prophylactics
• Difficult chronic migraine (≥ 15 per month)
• Botox candidates (Chronic Migraine failed on 3
prophylactics)
• Not sure of diagnosis?
• Other comorbid headache disorder?
• Difficult to address analgesic overuse
Finally, a few headache myths
• Tension-type headache is not “caused by stress”

• Refractive error does not cause headache – it causes

eyestrain

• Nearly 90% of patients with self or physician-diagnosed

“sinus headache” have migraine.
Headache Service, SGH
• Team
• Dr Niran Nirmalananthan
• Dr Usman Khan
• Dr Bhavini Patel
• Dr Katharine Pink
• Dr Arani Nitkunan (IIH / GCA)
• Ms Anne-Marie Logan
• Contact for advice:
• Niran Nirmalananthan or Anne-Marie Logan
• via Kinesis
• Urgent advice:
• Neurology Registrar / Acute Neurology Team bleep 7277
Summary
• Headache in primary care is overwhelmingly benign
and a positive diagnosis can be made

• Can usually be effectively managed in primary care

• Imaging needed in very few cases

• Refer, rather than scan, if uncertain