richard sylvester consultant neurologist homerton university hospital / nhnn

Richard SylvesterConsultant Neurologist Homerton University Hospital / NHNN

Vast majority requests are MRI for headache

Where does MRI fit in the management of headache?

What headaches present?

Managing headache – pearls and pitfalls

Developing an integrated pathway for headache

Correct diagnosis – history/examination

Effective management – knowledge

Tests valuable only in minority of cases

Homerton neurology OPD (Oct – Dec 2012)

94/352 (27%) patients main complaint headache96% primary (78% migraine, 13% TTH, 9% other)45% analgesia overuse1/3 previous imaging1/3 imaged after clinic85% discharged

>90% migraine>65% analgesia overuse

When GP diagnosis is migraine – correct 98%If GP diagnosis is not migraine – incorrect 82%

(Tepper et al, Headache 2004)

Recurrent attacks

Headache lasting 4–72 hours untreated

At least two symptoms of:Throbbing/pulsatingUnilateralModerate or severeWorsened by movement/avoids routine physical activity

And either:Nausea +/or vomitingPhotophobia or phonophobia

ICHD-2, 2004

Lifestyle – regular sleep, food/drink, reduce stress

Abortive – high dose NSAID/domperidone - triptan/domperidone

Prophylactic – propanalol, AEDs, amitriptylline

Education – migraine trust website

(Imaging – <1:2200 brain tumour)

UnderdiagnosisLack of all migrainous symptomsAbsence of aura (>80%)Chronic headache – analgesia overuse

UndermanagedAnalgesia overuse propagatedAbortives not used correctlyProphylactics - dose / length of treatment

NMC guidance for GPs

>14 days month

>2 days analgesic use per week

Any analgesic

Underlying primary headache

Reduces efficacy of prophylactics

Addiction pathway?

Primary TTH – featureless, no analgesia overuseCluster – 1-3 hrs, agitatedTACS – rare

Secondary‘Red flags’

Diagnose/exclude serious pathology

Relieve anxiety (patient / doctor)

Avoid referral to specialist (cost)

Patient choice

It excludes serious pathology

But headache alone is not a marker of structural pathology

‘red flag’ features are – need specialist input/imaging

Thunderclap headache (peak intensity 1-5mins lasting >1hr)Fever/systemic illness Focal neurology / seizuresCognitive declineNew onset daily headache in high risk group(>50yrs/cancer/immunosuppressed)Postural features suggestive low / high CSF pressure

It relieves anxiety

Maybe in the short term but not for longRCT imaging vs noneOutcome measure – anxiety scores / Is my headache caused by

something serious ?Less anxiety at 3 months but not at one year (Howard et al JNNP 2005)

Around 5% are not normal – more anxietyChiari malformationsArachnoid/Pineal cystsSmall meningiomas/aneurysmsWhite matter lesionsPituatary abnormalities

Avoids specialist referral and reduces costs

No cost benefit – minor reduction in referral rate(Wills et al, JNNP 2005)Open Access MRI with GP referral guidelines 169 scans in 12 monthsIncidentaloma rate: 3% No reduction in costs and minor reduction in referrals

Imaging doesn’t diagnose and manage symptoms

Patients want scans

Yes but they would prefer to get rid of their symptoms

Normal scan may lead to trivialising symptoms

Red flags

Triggered headache

Head injury

NODPH

Rare phenotypes

When I have little choice!

CT

short wait, good for fractures / large lesions / less incidentalomas but radiation, poor resolution

MRI – often need specific sequences

Trauma – GE/SWI?low CSF pressure – contrast TACS – pituitary imagingTN – brainstem sequencesMRA/MRV – arterial/venous pathology

Urgent - Neurology SPR Homerton / RLH

Routine - Email advice linehuh-tr.NeurologyHomerton@nhs.net

Red flags?Yes

Urgent? A&E / medics / neuro SPRYes

No Neurology OP Email advice service

No

Analgesia overuse?Yes Stop analgesics

success?No

?psychiatry input

Diagnostic pattern?

Yes

Headache diaryReview in 8/52 Diagnosis?

No

No

Neurology OP Email advice service

Migraine?Yes

Yes

No

Yes

TreatmentTriggersAbortiveProphylaxis

Neurology OP Email advice serviceNo

Primary care management e.g. TTH, musculoskeletal

No

Others – cluster, TACSTriggered, NODPH

Imaging

Imaging

Imaging

Always consider the aims and likely outcomes of brain imaging

There are limited indications for brain imaging in headache

Correct diagnosis and management are morereassuring than normal tests

Its usually migraine and analgesia overuse!

Migraine trusthttp://www.migrainetrust.org/

National migraine centrehttp://www.migraineclinic.org.uk/

BASHhttp://www.bash.org.uk/