managing headache in acute medicine
TRANSCRIPT
Managing Headache
in Acute Medicine
Ben LovellConsultant Physician in Acute Medicine
University College London Hospital
Some ED headache stats
Arrive by ambulance 31%
Median age 39
Instant peak 18%
Max intensity <1 hour 44%
“Worst ever” headache 37%
23%10/10 severity
Some ED headache stats
GCS <15 4%
Associated with neck stiffness 4.8%
Get a CT head 38%
Get an LP 4.7%
How to assess a headache
1. Assess for serious secondary causes
2. Assess for non-serious secondary causes
3. Assess for tension-type headache and migraine
4. Consider for less common causes of headache
Serious secondary causes
• Raised ICP
• SOL or IIH
• Malignancy elsewhere
• Bleeding
• Following trauma
• Neurological impairment
• Thunderclap
• GCA if >50
• Infective
• Fever/meningism
Thunderclap headaches
• About 50% of thunderclap headaches are not
• 6% of thunderclap headache are due to SAH
• 12% of SAH are missed on first presentation
• Kowalski RG, Claassen J, Kreiter KT et al. Initial misdiagnosis and outcome after subarachnoid
hemorrhage. JAMA 2004;291:866–9.
• The Ottawa rule
• Perry et al. Clinical Decision Rules to Rule Out Subarachnoid Hemorrhage for Acute Headache.
JAMA. 2013;310(12):1248-1255
• 2321 patients with thunderclap headache
Implications of Ottawa Rule
• If people screen negative they do not require
investigation for SAH
• If people screen positive, they may have SAH and
require investigation
So who needs LP?Perry Jeffrey J, Stiell Ian G, Sivilotti Marco L A, Bullard Michael J, Émond Marcel, Symington Cheryl et al. Sensitivity of computed
tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort
study BMJ 2011; 343 :d4277
Have SAH Don’t have SAH
CT positive 223 0
CT negative 17 2892
Sensitivity = 92.9% (few false negative CT scans)
Specificity = 100% (no false positive CT scans)
So who needs LP?Perry Jeffrey J, Stiell Ian G, Sivilotti Marco L A, Bullard Michael J, Émond Marcel, Symington Cheryl et al. Sensitivity of computed
tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort
study BMJ 2011; 343 :d4277
> 6 hours after
headache
onset
Have SAH Don’t have SAH
CT positive 102 0
CT negative 17 2060
Sensitivity = 85.7%
Specificity = 100%
So who needs LP?Perry Jeffrey J, Stiell Ian G, Sivilotti Marco L A, Bullard Michael J, Émond Marcel, Symington Cheryl et al. Sensitivity of computed
tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort
study BMJ 2011; 343 :d4277
< 6 hours after
headache
onset
Have SAH Don’t have SAH
CT positive 121 0
CT negative 0 832
Sensitivity = 100%
Specificity = 100%
GCA• 0.02% of > 50 year olds
• Mean age of onset is 75
• Usually women (8:1)
• Diagnosis
• 4% have normal ESR
• ESR may be suppressed by
• Statins
• Anti-inflammatories
• DMARDS
American College of Rheumatology
• > 3 of the following:
• Age >50
• New headache
• Temporal artery tenderness or loss of pulsation
• ESR>50
• Abnormal temporal artery biopsy
• Sensitivity = 94%, specificity = 91%
Treatment
• ‘Shoot first and ask questions later’
• Biopsy results remain abnormal 7 days post steroid
treatment
How to assess a headache
1. Look for symptoms of serious secondary causes
2. Assess symptoms of non-serious secondary causes
3. Assess for tension-type headache and migraine
4. Consider for less common causes of headache
Non-serious secondary
causes
• Medication-overuse
headache
• Sinusitis
• Dental abscess
• Generalised fever
• Otitis media
• TMJ dysfunction
Medication Overuse
Headache
• Criteria
• Pre-existing primary headache disorder
• Pain for >15 days/month
• >3 months
• Regular analgesia taken
• COMMON
Medication Overuse
Headache
• Treatment
• Education (76% cured at 18 months)
• Detoxification
• Effective treatment of primary headache
• Relapse is common
How to assess a headache
1. Look for symptoms of serious secondary causes
2. Assess symptoms of non-serious secondary causes
3. Assess for tension-type headache and migraine
4. Consider for less common primary causes of
headache
Migraine
• Criteria (ICHD 2013)
• Lasts between 4 hours - 72 hours
• Has 2 out of the following:
• Unilateral
• Pulsating
• Moderate to severe
• Aggravated by physical activity
• Has 1 out of the following:
• Nausea/vomiting
• Photophobia/phonophobia
At least 5
attacks!
Migraine
• POUND criteria
• Pulsatile
• One day duration
• Unilateral
• Nausea/vomiting
• Disabling
4 or more features =
92% likelihood of
migraine
Wilson JF. In the clinic. Migraine Ann Intern Med 2007;147(9): ITC11-1–ITC11-16
• Aura phase• One third migraineurs
• Less than 1 hour
• Mood change, body aches, change in bowel habit
Migraine
• Pain phase• 4 - 72 hours
• Associated with nausea, vomiting, phono/photophobia
• Postdrome
• Prodrome• 60% of sufferers
• 2 - 24 hours
• Mood change, body aches, change in bowel habit
Mathur V et al. eCollection 2016. High Frequency Migraine Is Associated with Lower Acute Pain
Sensitivity and Abnormal Insula Activity Related to Migraine Pain Intensity, Attack Frequency, and Pain
Catastrophizing .Front Hum Neurosci. 2016 Sep 29;10:489
Acute migraine
• It is crucial to:
• Intervene early, when the pain is still mild
• Use adequate drug doses and appropriate routes of
administration
• Antiemetic or prokinetic drugs should be co-administered to
facilitate absorption of the primary drug
• Take steps to avoid chronification of the headache and the
development of MOH
Antonaci F, Ghiotto N, Wu S, Pucci E, Costa A. Recent advances in migraine therapy. SpringerPlus. 2016;5:637. doi:10.1186/s40064-016-2211-8.
Opioids
• NICE:
• “Opioids are not recommended because they may
exacerbate nausea and will also increase the risk
of medication overuse headache.”
• BASH
• “Narcotics are NOT recommended for the
emergency treatment of migraine and their use
can be associated with delayed recovery”
Non-specific treatments• Paracetamol
• NNT =12
• NSAIDS
• Aspirin 900mg
• Ibuprofen/diclofenac/naproxen
• IV fluid
• Mixed evidence
• Dehydration is a known trigger for migraine
• Patients with migraine often become dehydrated
Specific treatments
• Triptans
• 5-HT1B/1D receptor agonists
• Inhibit neurotransmitter release at both peripheral and central
trigeminal nociceptive terminals
• Aborts migraine attack in 80%
Side effects
• ‘Triptan sensations’
• Flushing
• Paraesthesia
• Chest pressure
• Vasoconstriction, therefore C/I in:
• Uncontrolled HTN
• CAD
• Raynaud’s
TTH
• Lasts 30 mins - 7 days, and has 2 of the following:
• Bilateral
• Pressing/tightening
• Mild to moderate intensity
• Not aggravated by activity
• Does not cause nausea/vomiting, but may have
photo/phonopobia
Paracetamol 1000 mg may relieve headache pain, but the chance of the pain being relieved
entirely by two hours is low, about 2 in 10 (24%), but this is only very slightly greater than
the proportion who took placebo (about 1 in 5, or 19%)
NICE guidelines
• Listen to and address the person's concerns about their symptoms.
• Treat acute tension-type headache (TTH) with paracetamol,
aspirin, or a nonsteroidal anti-inflammatory drug (NSAID) such as
ibuprofen or naproxen.
• Advise people that the overuse of painkillers (prescribed or over-
the-counter) can lead to medication overuse headache.
• Do not treat acute TTH with opioids or triptans.
Long term management
• There is no evidence for:
• SSRI
• Botulism toxin
• Homeopathy
• Beta-blockers
• There is weak evidence for
acupuncture
• There is good evidence for:
• Amitriptyline
• Regular exercise
How to assess a headache
1. Look for symptoms of serious secondary causes
2. Assess symptoms of non-serious secondary
causes
3. Assess for tension-type headache and migraine
4. Consider for less common causes of headache
Trigeminal autonomic
cephalalgias• Unilateral (1/3 sidelocked headaches)
• Trigeminal autonomic features:
• Tearing
• Conjunctival injection
• Nasal stuffiness
• Eyelid drooping
• Agitated patients
• A family of 5 headaches:
• Cluster headache
• SUNCT
• SUNA
• Paroxysmal hemicrania
• Hemicrania continua
Trigeminal autonomic
cephalgias
Cluster headache• High flow oxygen (15L via
NRBM) results in 70% patients
pain free at 15 mins
• Cohen AS et al. High-flow oxygen for treatment
of cluster headache: a randomized trial. JAMA
2009; 302(22): 2451-2457.
• Sumatriptan (sc) aborts the
attack in 50%, and minimises
pain in 75%
• Law S et al. Triptans for acute cluster
headache. Cochrane Database of Systematic
Reviews 2010, Issue 4. Art. No.: CD008042.
“Analgesics have no place in the treatment of
cluster headache” - BASH 2010