RED FLAGS IN HEADACHE; RED FLAGS IN HEADACHE; A HEADACHE FOR THE MAU A HEADACHE FOR THE MAU

DOCTORDOCTOR

FAYYAZ AHMEDFAYYAZ AHMEDCONSULTANT NEUROLOGISTCONSULTANT NEUROLOGIST

HULL & EAST YORKSHIRE HULL & EAST YORKSHIRE HOSPITALS NHS TRUSTHOSPITALS NHS TRUST

ObjectivesObjectives

Recognising red flags in HeadacheRecognising red flags in Headache

Clinical Features of Serious Clinical Features of Serious Headache DisordersHeadache Disorders

Investigation plan and further Investigation plan and further referralreferral

HEADACHESHEADACHES

One of the commonest symptomOne of the commonest symptomAccount for 30% GP and 50% Account for 30% GP and 50%

Neurology ReferralsNeurology Referrals95% of the population at some stage 95% of the population at some stage

experience headachesexperience headaches15-19% of Acute Medical Admissions15-19% of Acute Medical Admissions(1)(1), ,

55% of Neurology in A & E55% of Neurology in A & E(2)(2)

1. Weatherall M., J RCP Edinb 2006; 36: 196-2001. Weatherall M., J RCP Edinb 2006; 36: 196-2002. Craig J., Patterson V., Roche L., JamisonJ., Accident and Emergency Neurology: time for a 2. Craig J., Patterson V., Roche L., JamisonJ., Accident and Emergency Neurology: time for a

reappraisal? Health Trends, 1997, 29, 89-91reappraisal? Health Trends, 1997, 29, 89-91

DILEMMA IN MAU/A&EDILEMMA IN MAU/A&E

DILEMMA IN MAU/AEDILEMMA IN MAU/AE

AM I DEALING WITH A SERIOUS AM I DEALING WITH A SERIOUS HEADACHE ?HEADACHE ?

DO I URGENTLY INVESTIGATE OR ASK DO I URGENTLY INVESTIGATE OR ASK FOR HELP NOW OR AS AN OP ?FOR HELP NOW OR AS AN OP ?

WHO DO I ASK FOR HELP; WHO DO I ASK FOR HELP; NEUROLOGIST OR NEUROSURGEON?NEUROLOGIST OR NEUROSURGEON?

AM I OK TO SEND THIS PATIENT AM I OK TO SEND THIS PATIENT HOME?HOME?

SERIOUS HEADACHESSERIOUS HEADACHES

Subarachnoid HaemorrhageSubarachnoid Haemorrhage

Brain Tumours or Space Occupying Brain Tumours or Space Occupying Lesion (SOL)Lesion (SOL)

Infections like Meningitis, EncephalitisInfections like Meningitis, Encephalitis

Temporal arteritisTemporal arteritis

RECOGNISE SERIOUS RECOGNISE SERIOUS HEADACHESHEADACHES

RED FLAG HEADACHESRED FLAG HEADACHES

Hyperacute onset no previous historyHyperacute onset no previous history

Gradually progressive no previous historyGradually progressive no previous history

Presence of any neurological signsPresence of any neurological signs

Headaches above the age of 60Headaches above the age of 60

Change in characteristics or patternChange in characteristics or pattern

NON URGENT HEADACHESNON URGENT HEADACHES

Round the Clock for > 3 monthsRound the Clock for > 3 monthsNo Neurological SignsNo Neurological SignsAcute Exacerbations of Known Acute Exacerbations of Known

MigrainesMigrainesEpisodic Headaches > 6 months with Episodic Headaches > 6 months with

clear headache free intervalsclear headache free intervals

Thunderclap Headache (TCH)Thunderclap Headache (TCH)

Peaks within a minute Peaks within a minute Primary and Secondary (Clinically cannot Primary and Secondary (Clinically cannot

differentiate)differentiate)11

Primary TCH – Diagnosis of exclusion Primary TCH – Diagnosis of exclusion SAH – CT/LP earlier or CTA laterSAH – CT/LP earlier or CTA later Arterial Dissection – Focal Neurological signsArterial Dissection – Focal Neurological signs Pituitary Apoplexy – CT/MRI abnormalPituitary Apoplexy – CT/MRI abnormal Venous Sinus Thrombosis – Raised CSF, CTV Venous Sinus Thrombosis – Raised CSF, CTV Spontaneous Intracranial Hypotension –Typical history Spontaneous Intracranial Hypotension –Typical history

1. Linn et al JNNP 1998:65; 791-31. Linn et al JNNP 1998:65; 791-3

SAHSAH

11 per 100,00011 per 100,000 85% Saccular Aneurysm, 10% perimensephalic 85% Saccular Aneurysm, 10% perimensephalic

5% AVM5% AVM

Peaks within a minute and last at least an hourPeaks within a minute and last at least an hour Worst EverWorst Ever

May be associated with LOCMay be associated with LOC NV Photo/phonophobia NV Photo/phonophobia Neck Rigidity, Kernig’s signNeck Rigidity, Kernig’s sign

SAHSAH

CT scan SensitivityCT scan Sensitivity11

97% within 12 hours97% within 12 hours 85% after 24 hours85% after 24 hours 76% after 48 hours76% after 48 hours 58% after 5 days58% after 5 days

LP Xanthocromia LP Xanthocromia 100% 12 hrs – 2 weeks100% 12 hrs – 2 weeks 70% week 370% week 3 40% week 440% week 4

1. Van der Wee et al JNNP 1995 1. Van der Wee et al JNNP 1995

SAH – MISDIAGNOSISSAH – MISDIAGNOSIS

ReasonsReasons11

The diagnosis was not consideredThe diagnosis was not considered Failure to understand limitations of CTFailure to understand limitations of CT Failure to properly perform / analyse CSFFailure to properly perform / analyse CSF Wrong investigation – MRI/MRAWrong investigation – MRI/MRA

1 in 20 SAH patients are missed in A & E1 in 20 SAH patients are missed in A & E22

1.1. NEGM 2000, 342; 29-36NEGM 2000, 342; 29-36

2.2. Stroke 2007, 38; 1216Stroke 2007, 38; 1216

SAH - MISDIAGNOSISSAH - MISDIAGNOSIS

Instantaneous headaches only in 50%Instantaneous headaches only in 50% 1 in 6 SAH may present with a fit1 in 6 SAH may present with a fit 1-2% present with acute confusion 1-2% present with acute confusion LP is traumaticLP is traumatic Focusing on hypertension and arrhythmiaFocusing on hypertension and arrhythmia

RECENT AND PROGRESSIVE RECENT AND PROGRESSIVE HEADACHESHEADACHES

weeks to < 3/12weeks to < 3/12EXCLUDEEXCLUDE

SOLSOLCerebral Venous Sinus ThrombosisCerebral Venous Sinus ThrombosisIdiopathic Intracranial HypertensionIdiopathic Intracranial Hypertension> 55 Consider Temporal Arteritis > 55 Consider Temporal Arteritis

NEW DAILY PERSISTENT HEADACHESNEW DAILY PERSISTENT HEADACHESDiagnosis of exclusionDiagnosis of exclusionDaily unremitting from onset Daily unremitting from onset Migrainous or TTHMigrainous or TTH

SYMPTOMS of Raised ICPSYMPTOMS of Raised ICP

Headaches worse on straining and Early Headaches worse on straining and Early MorningMorning

Nausea and VomitingNausea and Vomiting DrowsinessDrowsiness Visual SymptomsVisual Symptoms SeizuresSeizures

SIGNS of Raised ICPSIGNS of Raised ICP

Impairment in Conscious Level (GCS<15)Impairment in Conscious Level (GCS<15) PapilloedemaPapilloedema HypertensionHypertension BradycardiaBradycardia False localising signs such as VI N palsyFalse localising signs such as VI N palsy Focal Neurological SignsFocal Neurological Signs

CTCT

MeningiomaMeningioma

G.B.MG.B.M

Cerebral Cerebral MetastasisMetastasis

Cerebral Venous ThrombosisCerebral Venous Thrombosis

Female, Smoker, OCP, PostpartumFemale, Smoker, OCP, Postpartum

Dehydration, HyperviscosityDehydration, Hyperviscosity

Drowsy, Seizures, Focal SignsDrowsy, Seizures, Focal Signs

Cerebral Venous ThrombosisCerebral Venous Thrombosis

Clinical SuspicionClinical Suspicion

CT Venogram/MRACT Venogram/MRA

AnticoagulationAnticoagulation

Benign Intracranial Benign Intracranial HypertensionHypertension

Female, Overweight, Smoker, OCPFemale, Overweight, Smoker, OCP

Visual SymptomsVisual Symptoms

PapilloedemaPapilloedema

Benign Intracranial HypertensionBenign Intracranial Hypertension

Clinical SuspicionClinical Suspicion

CT/MRI MRACT/MRI MRA

Lumbar PunctureLumbar Puncture

Acetazolamide/Topiramate/DiureticAcetazolamide/Topiramate/Diuretic

TEMPORAL ARTERITIS; FeaturesTEMPORAL ARTERITIS; Features

Uncommon below the age of 55Uncommon below the age of 55Women twice as much as MenWomen twice as much as Men

Common in British / ScandinavianCommon in British / ScandinavianFairly Uncommon in Asian/AfricansFairly Uncommon in Asian/Africans

Bengtsson B-A, Malmvall BE. Giant Cell Arteritis, Acta Med Scand, 1982;658:1-102Bengtsson B-A, Malmvall BE. Giant Cell Arteritis, Acta Med Scand, 1982;658:1-102

TEMPORAL ARTERITIS; SymptomsTEMPORAL ARTERITIS; Symptoms

Recent onset on uni or bilateral temporal Recent onset on uni or bilateral temporal HeadachesHeadaches

Cutaneous AllodyniaCutaneous Allodynia Jaw ClaudicationJaw Claudication

Systemic Symptoms Systemic Symptoms Pain and aching in Shoulder/Pelvic girdle Pain and aching in Shoulder/Pelvic girdle

musclesmuscles

TEMPORAL ARTERITIS; DiagnosisTEMPORAL ARTERITIS; Diagnosis

Clinical SuspicionClinical Suspicion

ESR/PV and CRP Normal < 1%ESR/PV and CRP Normal < 1%

Temporal Artery Biopsy – ControversialTemporal Artery Biopsy – Controversial

SteroidsSteroids

Hayreh SS, Podhajsky PA, Raman RI. Giant Cell Arteritis; Validity and Reliability of various Hayreh SS, Podhajsky PA, Raman RI. Giant Cell Arteritis; Validity and Reliability of various diagnostic criteria. Am j Ophthalmol 1997;123:285-296.diagnostic criteria. Am j Ophthalmol 1997;123:285-296.

FEBRILE HEADACHES; DAYSFEBRILE HEADACHES; DAYS

Meningitis – Viral, BacterialMeningitis – Viral, Bacterial

EncephalitisEncephalitis

ENCEPHALITIS: Symptoms/SignsENCEPHALITIS: Symptoms/Signs

Headaches and altered conscious Headaches and altered conscious level level

SeizuresSeizuresFocal Signs Focal Signs

ENCEPHALITIS: DiagnosisENCEPHALITIS: Diagnosis

CT/MRI (Diffuse or Focal Oedema)CT/MRI (Diffuse or Focal Oedema)

EEG (Slow waves over affected area)EEG (Slow waves over affected area)

CSF (Lymphocytes)CSF (Lymphocytes)PCR positive for HSV-1,VZVPCR positive for HSV-1,VZV

Acyclovir Acyclovir

Headache that Needs Urgent ImagingHeadache that Needs Urgent ImagingBASH guidelinesBASH guidelines

Clinical signs presentClinical signs present Pronounced signs of raised intracranial Pronounced signs of raised intracranial

pressurepressure Change in cognitive functional personalityChange in cognitive functional personality Relevant systemic diseaseRelevant systemic disease Worst headache ever particularly if Worst headache ever particularly if

crescendo is reached in minutes or rapidly crescendo is reached in minutes or rapidly deterioratingdeteriorating

SUMMARYSUMMARY

Serious Causes are UncommonSerious Causes are Uncommon

SAH, Meningitis, Encephalitis SOL and TA SAH, Meningitis, Encephalitis SOL and TA are the main serious headachesare the main serious headaches

Refer to Neurosurgeon (SAH) or Refer to Neurosurgeon (SAH) or Neurologists when in doubtNeurologists when in doubt

JOINJOIN

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Contact Contact Debbie.Buttle@hey.nhs.ukDebbie.Buttle@hey.nhs.uk