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
Special rates for Special rates for Trainees/Nurses/TherapistsTrainees/Nurses/Therapists
Electronic or Paper copies of CephalalgiaElectronic or Paper copies of Cephalalgia Invitation to BASH meetings Invitation to BASH meetings BASH NEWSLETTER (www.bash.org.uk) BASH NEWSLETTER (www.bash.org.uk)
BASH MEETINGS IN 2011/12BASH MEETINGS IN 2011/12
GLASGOW GLASGOW JUNE 15-16JUNE 15-16 20112011PLYMOUTHPLYMOUTH OCTOBER OCTOBER 20112011LONDONLONDON APRILAPRIL 20122012KEELEKEELE SEPTEMBER SEPTEMBER 20122012
Contact Contact [email protected]@hey.nhs.uk