![Adult with Headache
Emergency
symptoms?1 Refer to appropriate on-call hospital team
Red flags?3
Use Advice & Guidance
Service or refer general neurology
Can you make a
diagnosis of
primary headache
disorder?
Prescribe acute treatment (< 10 days/month)4
Refer to headache
clinic
Inadequate response to
migraine preventatives. Is it
chronic daily headache
(>15/7 per month)?
Use headache diary
Migraine or tension headache4 ?
Giant cell arteritis?2
• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries
• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura
• Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect
from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.
Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger
avoidance, stress management techniques, normalise BMI, daily aerobic exercise)
Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-
a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;
b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:
teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes
paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.
c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred:
riboflavin 400mg - patients source or acupuncture
Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic
overuse.
Cluster
headache?5
Try acute
treatments5
Check ESR and CRP
Prednisolone 60mg o.d. immediately
Consider urgent referral to rheumatology as
appropriate2 (Need temporal artery biopsy within 2
weeks of starting prednisolone)
Yes
Yes
No
No
No
No
Yes
Northern East Headache Management Guideline
November 2015
Refer Neurology
emergency clinic
(fax 0191 2824370)
Yes
Yes
No](https://image.slidesharecdn.com/gpqa2016-160616190857/85/GP-Q-A-8-320.jpg)
GP Q&A
- 1. Neurology Shared Learning for GPs 26th May 2016
- 2. GP liaison • Education – Feb 25th – May 26th • Communication/referrals – A+G – Routine clinics – Rapid access clinics • Pathways – Headache (almost done) – Tremor/PD (next) [email protected] [email protected]
- 3. Outline • • Programme • 9:15 Introduction • 9:20 Seizures and seizure mimics • Shan Ellawala • 10:10 Small group teaching • Case discussions TW, MD, JG, NW, KP • 11:10 Coffee • 11:30 Atypical headache • Joe Guadagno • 12:10 Quick fire top neurology tips (based on requests from GPs) • Naomi Warren and Martin Duddy • 12:50 Close
- 4. Neurology Q+A for GPs Drs Naomi Warren + Martin Duddy RVI 26th May 2016 [email protected]
- 5. How to manage chronic headaches How to manage severe tension headache
- 6. NICE 2012 • Important to make a +ve diagnosis
- 7. NICE 2012 • Do not scan primary headaches for reassurance
- 8. Adult with Headache Emergency symptoms?1 Refer to appropriate on-call hospital team Red flags?3 Use Advice & Guidance Service or refer general neurology Can you make a diagnosis of primary headache disorder? Prescribe acute treatment (< 10 days/month)4 Refer to headache clinic Inadequate response to migraine preventatives. Is it chronic daily headache (>15/7 per month)? Use headache diary Migraine or tension headache4 ? Giant cell arteritis?2 • Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries • If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura • Ensure not overusing analgesics or triptans6: Occurs if any of acutes being taken on average >2 days per week. Also similar effect from caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset. Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger avoidance, stress management techniques, normalise BMI, daily aerobic exercise) Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:- a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day; b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE: teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression. c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse. Cluster headache?5 Try acute treatments5 Check ESR and CRP Prednisolone 60mg o.d. immediately Consider urgent referral to rheumatology as appropriate2 (Need temporal artery biopsy within 2 weeks of starting prednisolone) Yes Yes No No No No Yes Northern East Headache Management Guideline November 2015 Refer Neurology emergency clinic (fax 0191 2824370) Yes Yes No
- 9. Migraine - misdiagnoses 50% misdiagnosed 4-72 hrs – can be longer 75% neck pain <33% vomiting Often coexist Chronic - 15 days/month over 3/12 – features of tension/MOH
- 10. Management • Identify triggers – Stress/sleep dep/diet • Massage/acupuncture etc • Withdraw any overused meds • Headache Diary
- 11. Management Acute: ASA 900mg NSAIDs – ibuprofen (dicofenac pr) +/-Antiemetics Domperidone/metoclop best Occ codeine? *caution Combination asa + caffeine + para
- 12. Triptans For use at onset headache Effective in 50% Delivery methods Oral – all – sumatriptan cheapest S/L – riza + zolmitriptan S/C or nasal - sumatriptan If no response try alternative Combination with ASA/NSAID C/I IHD or severe hypertension Caution with hemiplegic migraine
- 13. Prophylaxis – general principles • Given if affecting QOL • Titrated slowly • Trial 6-8 weeks • If effective consider withdrawal after 6- 12/12
- 14. Prophylaxis • Propranolol LA 80mg - 240mg – Caution asthma, bradycardia, PVD • Topiramate 25mg – 50mg bd – Caution kidney stones/depression/teratogenicity? • Amitriptyline 10mg – 75mg – Good if chronic/mixed • Valproate 800-1200mg/day – Caution young women • Gabapentin up to 2400mg/day • Pizotifen minimal benefit
- 15. Alternatives: • Atenolol/metoprolol • Nortripyline • Venlafaxine 75-150mg • Bo tox • recent license chronic migraine • >3 prior Tx • No MOH
- 16. Who to refer? • Unsure of diagnosis • Atypical migraine – Motor weakness – Diplopia – Poor balance • If adequate trial propranolol/amitrip ineffective • Patient reassurance
- 18. Differential Diagnosis • Drugs – Da blocking drugs • Antipsychotics • Antiemetics – Inhalers – B agonists – Ca channel blockers – Li – Valproate – Digoxin • etc • PD • Thyrotoxicosis – Check TFTs • Anxiety • ET • Dystonic
- 19. Essential Tremor • Activity • Bimodal age onset • ½ alcohol benefit • ½ FH • Postural/action, symmetrical 4-12 Hz • +/- head (late), jaw, voice • Treatment – Propranolol LA 80mg – 240mg, Topiramate 25mg – 100mg – primidone, gbp. – Rarely: deep brain stimulation
- 20. Peripheral neuropathy – history, investigations and who to refer? • Sensory (occ motor) disturbance feet • Feet before hands • Worse at rest/night • Exam – reduced/absent AJ • Investigations: – Glucose, HBA1C, TFT, B12, Folate, ESR, Autoantibodies, Igs and electrophoresis • Refer – if motor symptoms +/or significant sensory symptoms and no cause found
- 21. CTS/ulnar CTS – most common cause of sensory disturbance hands – night + carrying Thumb abduction/sensory Open access NCS Ulnar – small muscles hand/sensory Refer neurology
- 22. GP Q&A Dr Martin Duddy Consultant Neurologist Royal Victoria Infirmary Newcastle upon Tyne, UK
- 23. review of how to do a quick neuro exam • “brief neuro exam 2016” • U of Birmingham; David Nicholl • https://www.youtube.com/watch?v=q56WgXvn0iU
- 24. what test reliably rules out MS? • composite diagnosis • depends on degree of clinical suspicion • normal MRI with significant symptoms – role of spinal MR • good story (esp with signs) – evoked potentials – LP
- 26. when to suspect MS in sensory symptoms • anatomical distribution • time course • linguistics • concordant motor/autonomic symptoms • signs
- 27. MS: common pitfalls in dx, e.g. what’s been missed by GPs • sensitivity/specificity • misdiagnosed past episodes • missed symptoms – bladder/bowel – erectile dysfunction – Lhermitte’s – Uthoff’s (heat-sensitive symptomatology)
- 28. management/referral for abnormal sensation, i.e. pins and needles/numbness tingling • clinical context • is the distribution consistent with: – peripheral mononeuropathy – peripheral neuropathy – radicular pathology – myelopathy – central disease • does the time course suggest pathological process? • congruent motor/autonomic/reflex changes • is the presentation predominantly neurological? – pain/ fatigue/ anxiety