14/06/2018 LEARNING OBJECTIVES HOW TO MAKE THE PATIENT 1. - - PDF document

▶

Aug 27, 2022 337 likes •393 views

14/06/2018 LEARNING OBJECTIVES HOW TO MAKE THE PATIENT 1. Understand the features of common primary and secondary headache disorders that may present WITH HEADACHE NOT A to optometrists 2. Employ an appropriate mix of open and closed

SLIDE 1

14/06/2018 1

HOW TO MAKE THE PATIENT WITH HEADACHE NOT A HEADACHE FOR YOU

DR MARK WEATHERALL CONSULTANT NEUROLOGIST BUCKINGHAMSHIRE HEALTHCARE NHS TRUST

LEARNING OBJECTIVES

1. Understand the features of common primary and secondary headache disorders that may present

to optometrists

2. Employ an appropriate mix of open and closed questions to elicit a headache history from patients
3. Recognise significant symptoms that may indicate a serious underlying neurological disorder
4. Recognise significant examination findings that may indicate a serious underlying neurological

disorder

5. Advise patients and their GPs on appropriate further assessment or investigation of headache

HOW DO WE CLASSIFY HEADACHES? PRIMARY HEADACHE DISORDERS ARE COMMON

Global prevalence of migraine

North America

9.7%

Central / South America

16.4%

Africa

10.4%

Asia and Australia

10.1% Global prevalence: Headache: 47% Migraine: >10% Lifetime prevalence: Headache: 66% Migraine: 14% Migraine ranks among the 10 leading causes for years lived with disability Europe 11.4%

PRIMARY HEADACHE DISORDERS ARE COMMON

4 5 7.4 6.5 5 1.6 6.4 17.3 24.4 22.2 16 5 5 10 15 20 25 30 12–17 18–29 30–39 40–49 50–59 >60 Men Women

COMMON PRIMARY HEADACHE CHARACTERISTICS

Moderate/severe intensity - throbbing Mild/moderate intensity – pressing/tightening MIGRAINE TENSION-TYPE Severe/very severe intensity CLUSTER Pain type CHARACTERISTICS Unilateral/bilateral Bilateral Unilateral, typically around/behind the eye Headache location 4-72 hours 30min to 1 week 15-180 mins Headache duration Recurrent, variable frequency Infrequent to daily One or more daily during bouts Headache frequency Nausea, vomiting, phonophobia, photophobia, pain aggravated by activity Pericranial tenderness, phonophobia, not aggravated by activity Tearing, conjunctival injection, nasal congestion, facial sweating, ptosis, eyelid edema Other symptoms Affects 2-3 times more women than men More common in women than men Affects 3 times more men than women Demographics

SLIDE 2

14/06/2018 2

MOST DISABLING HEADACHES ARE MIGRAINES

‘migraine’ is the disorder and the attack
this is analogous to epilepsy: the disorder (epilepsy) is a tendency to the attacks (seizures/fits)
In migraine both share the same name
the disorder is characterised by:
the tendency to repeated attacks
triggers (sleep, food, weather, chemical (EtOH, GTN), hormonal, sensory, stress/relaxation
certain associations (hangovers, motion sickness, childhood vomiting)
family history

MIGRAINE = HEADACHE PLUS IS IT MIGRAINE OR TENSION-TYPE HEADACHE?

recurrent disabling headaches are migraines until proven otherwise
ask about the worst type of attack
the SPECTRUM study showed that in patients whose worst headache fulfilled the criteria for migraine, all

their headaches (however mild/severe) responded to triptans, whereas those with purely TTH did not

TTH rarely stops people doing what they want to do
TTH is not associated with nausea or light sensivitity
chronic TTH is rare

IS IT MIGRAINE OR CLUSTER HEADACHE?

look at the pattern of attacks: people do not get >1 migraine attack/day
migraine rarely wakes people from sleep
autonomic symptoms are seen in people with migraine attacks, but are rarely as prominent as they

are in cluster headache and related conditions

cluster patients are restless & agitated; migraine patients want to keep still & quiet

A BASIC SET OF QUESTIONS

How did your headaches start (suddenly/gradually/always had them)?
How long do your headaches last (minutes/hours/days)?
Where do you feel the pain (same place every time/different places)?
Do you get more than one attack in a day?
Do you experience nausea or worsening of the pain with exposure to normal levels of light?
What do you do when you get the pain (be still & quiet/pace restlessly)?

SLIDE 3

14/06/2018 3

‘RED FLAGS’: NICE GUIDELINES 2015

worsening headache with fever ; sudden-onset headache

reaching maximum intensity within 5 minutes; new-onset neurological deficit; new-onset cognitive dysfunction; change in personality; impaired level of consciousness; recent (typically within the past 3 months) head trauma; headache triggered by cough, Valsalva (trying to breathe out with nose and mouth blocked) or sneeze; headache triggered by exercise; orthostatic headache (headache that changes with posture); symptoms suggestive of giant cell arteritis; symptoms and signs of acute narrow angle glaucoma; a substantial change in the characteristics of their headache

SERIOUS CAUSES OF HEADACHE WHEN TO WORRY ABOUT HEADACHES: HISTORY

Thunderclap headache (subarachnoid haemorrhage)
Headache with focal neurology (brain lesion)
Persistent worsening headache (meningitis, brain lesion, raised ICP)
Episodic headaches brought on by manoeuvres that raise intracranial pressure (raised ICP, colloid cyst)
coughing, sneezing, straining
Headache associated with a red eye and impaired visual acuity (acute angle-closure glaucoma)
New headaches in anyone > 55 years (giant cell arteritis)

WHEN TO WORRY ABOUT HEADACHES: EXAMINATION 2 THINGS TO RECOGNISE: 1. MIGRAINE AURA 2 THINGS TO RECOGNISE: 2. VISUAL SNOW

SLIDE 4

14/06/2018 4

WHAT TO TELL THE PATIENT AND THE GP

if papilloedema, URGENT REFERRAL within 24 hours
if acute glaucoma, URGENT REFERRAL within 24 hours
if suspected temporal arteritis, URGENT REFERRAL within 24 hours
if symptoms suggestive of cluster headache, advise patient makes urgent appointment with GP
if persistent/daily headaches, or severe headaches uncontrolled with current treatment, advise

patient to make routine appointment with GP