On Tuesday September 6th 2016, Queen Square Private Healthcare welcomed an audience of GPs and charitable organisations to the lecture theatre in Queen Square for a very popular event in the 2016 Queen Square GP Seminar series. For this event, we were very pleased to host Dr Manjit Matharu, a Consultant Neurologist at the National Hospital for Neurology and Neurosurgery and a leading authority on the topic of headache. He is a member of the NICE Guideline Development Group for Headache, and Clinical Lead for the Headache Group at the National Hospital, a multidisciplinary outpatient and inpatient service which offers unique treatments for a range of pain disorders.
Headache is a common and disabling problem, accounting for 4.44 consultations out of every 100 registered patients in general practice and for 20-25% of all neurology consultations. It can be highly disabling with migraine now recognised as one of the 20 most common causes of years of life lived with disability. 100,000 people are absent from work or school daily, contributing to 25 million lost work or school days each year.
Despite guidelines for the diagnosis and management of headache being available, it is still a misdiagnosed and undertreated problem. Effective treatment is often possible but depends on the correct diagnosis of the exact headache disorder, a task complicated by the fact that the differential is large (over 300 causes). Therefore, a systematic approach to diagnosis is essential.
Clinical Approach to Headache
Dr Matharu proceeded to describe a clinical approach to headache which should always start with a detailed history and examination. He explained that the crucial first step is to identify any red flags which might suggest secondary causes for the patient’s headaches. Dr Matharu summarised red flags for further investigation or referral as:
- Age – New onset or different headache in anyone over the age of 50 years
- Onset – Sudden, abrupt onset or severe headache (thunderclap)
- Severity – “Worst headache ever”
- Progression – Headaches that progressively get worse over time
- Systemic symptoms – Fever, neck stiffness, rash, weight loss
- Neurological Signs – Papilloedema, focal signs, confusion, impaired consciousness
- Aura – Fixed or prolonged aura for longer than 1 hour
- Triggers – Headaches that start with exercise, sexual intercourse, coughing or sneezing
- Risk factors for secondary headache – HIV, cancer, malignant hypertension, post trauma
Only 0.89% of all headaches presenting to primary care will be secondary to an underlying problem, but ruling out secondary causes early has a number of benefits including detection of significant and treatable lesions and allaying patient anxiety about having an underlying problem. However, Dr Matharu explained that caution should be exercised when considering medical imaging in all cases of headache. Incidental findings on MRI brain imaging are common (13.5% of the population are at risk of incidental findings), and imaging will often only provide a short term decrease in patient anxiety. In fact, patient satisfaction has been shown to relate more to the quality of the consultation with the doctor, than the procedures arranged.
Dr Matharu summarised secondary headaches and their implication for clinical practice by saying:
- Refer all thunderclap/”worst ever” headache acutely
- All patients over the age of 50 (especially smokers) should command full attention and would normally involve a lower threshold for imaging and full neurological examination
- Try to pinpoint a primary headache diagnosis, even if it takes several appointments in primary care. A Headache diary can be useful.
- Reassure anxious patients using a neurological examination
- Request imaging as little as possible and always with informed consent prior to arranging a scan.
The overwhelming majority of headache presenting to primary care will be primary headache, with 95% being migraine, 4% being tension type headache and 0.1% being cluster headache. Other types of primary headache disorder are rare. 1-2% are likely to be medication overuse headache.
Once secondary causes are ruled out, Dr Matharu explained that the duration of the headache can be a useful way of narrowing down the differential diagnosis. Long lasting headache (a duration of longer than 4 hours) are by far the most common.
Migraine are classified as episodic attacks of headache lasting between 4-72 hours where the headache is always accompanied by either nausea and/or vomiting, and either photophobia and/or phonophobia. In addition, migraine headaches must have at least two of the following features:
- Unilateral location
- Moderate or severe pain intensity
- Aggravation by routine physical activity.
Dr Matharu explained how the pathophysiology of migraine is now becoming better understood.
Tension Type Headache
Dr Matharu then proceeded to tension type headache which are described as a featureless headache. They last between 30 minutes and 7 days, do not involve nausea or vomiting and involve photophobia or phonophobia, but not both. In addition, tension type headache must have at least two of the following features:
- Not throbbing
- Mild or moderate pain intensity
- Not aggravated by movement
Dr Matharu explained that following key studies, episodic, disabling primary headache with an otherwise normal exam should be considered migraine in the absence of any contradictory evidence.
Dr Matharu then spoke about abortive and preventative treatments for migraine. Various nonspecific and specific treatments exist, but opiate based and mixed analgesics should be avoided. The NICE guidelines for abortive treatments recommend a combination therapy of either an oral triptan and a NSAID, or an oral triptan and paracetamol. Anti-emetics may be used in addition to other acute treatments, even in the absence of nausea or vomiting. Ergots or opioids should not be offered for acute treatment.
Preventative agents should be used when patients experience more than 5 headaches per month, although they can be considered when frequency is 3-4 per month. The general rules for preventive treatments of migraine are:
- To consider when headache frequency is greater than 5 days per month
- Start low and go slow with doses
- Aim of the optimum migraine prevention dose
- There may be a lag of 2 months on optimum dose before efficacy emerges. Advise patients to remain on optimum dose of 3-4 months
- If effective, keep up treatment for 3-6 months before considering a gradual taper
- Some patients will relapse and need long term treatment.
Dr Matharu explained that the use of Botox is recommended as an option for prophylaxis of headaches in adults with chronic migraine, defined as headaches on at least 15 days per month, of which 8 days are with migraine. Non pharmacological treatments are also available which may be used based upon patient preference, tolerance, history of overuse, pregnancy or nursing. Such treatments now include acupuncture, relaxation training, biofeedback and cognitive behavioural therapy. However, there is currently insufficient evidence to support the use of TENS, cervical manipulation, or hypnosis. Emerging therapies also include non-invasive neurostimulation techniques (transcranial magnetic stimulation, vagal nerve stimulation) and invasive neurostimulation such as occipital nerve stimulation.
Treatment of Tension Type Headache
Dr Matharu explained that current guidelines for the management of tension type headache include:
- Acute treatment with aspirin, paracetamol or an NSAID (not opioids)
- Prophylactic treatment with a course of acupuncture for chronic tension type headache.
Medication Overuse Headache
The discussion then proceeded to the issue of medication overuse headache which develops through the chronic overuse of medication taken to treat headache or other pain. This type of headache is defined as headache on more than 15 days per month in a patient with a pre-existing headache disorder and a regular overuse for longer than 3 months of acute symptomatic treatment drugs, during which time headaches have developed or worsened. Overuse of all headache medication taken on an ad hoc basis may result in medication overuse headache and is most commonly associated with the use of simple analgesics for more than 15 days per month and/or opioids, ergots, combination analgesics or triptans on more than 10 days per month.
If medication overuse headache is suspected, all overused acute medication should be stopped abruptly for at least 1 month. Patients should be advised that symptoms are likely to worsen before improving and therefore, follow up and support should be offered. Constant review is warranted.
Finally, Dr Matharu proceeded to discuss the most common type of trigeminal autonomic cephalgia, cluster headache. These are defined as:
- Orbital, supraorbital or temporal pain
- 15-180 minutes in duration
- Frequency of 1 every other day to 8 daily
Associated symptoms also include autonomic symptoms (lacrimation, ptosis, nasal congestion etc.) and a sense of restlessness or agitation.
Oxygen (100% at a flow rate of 12 litres per minute) and subcutaneous or nasal triptan should be offered for the cute treatment of cluster headache. Paracetamol, NSAIDS, opioids, ergots or oral triptans should not be offered for the acute treatment of cluster headache.
At the end of what was a comprehensive and highly engaging seminar, Dr Matharu concluded by saying that primary headache syndromes have a high prevalence and are the cause of significant disability. Considerable progress has been made recently in unravelling the biology of these disorders, and good treatments are already available, with new treatments in development.
Following the presentation, delegates were invited to the Queen Square Private Consulting Rooms where they enjoyed a drinks and canapes reception and the chance to network with their colleagues and the evening’s speaker.
We are very grateful to Dr Matharu for sharing his expertise with us on this topic. For those wanting further information, he runs an annual day long course at the Royal College of Physicians, details of which can be found at headachemasterclass.com.
The next Queen Square GP Seminar will take place on Tuesday November 8th 2016, and will involve a seminar on Dizziness by Professor Adolfo Bronstein.