Thread by @georgebellstarr

Headaches and Neurology with Dr Peter Miller.

Possibly the most popular presentation of the conference so far.

Starting with some hard hitting facts:

Headache = brain tumour = 1:1,000
Likelihood of migraine diagnosis being right = 9/10

#SWPiPC

PT with a headache? Some 🚩

🚩>50
🚩 Pregnancy
🚩Thunderclap
🚩Hx of malignancy or immunosuppressives

Any of these could be concerning.

Thunderclap, need to be asking speed of onset and is this the worst headache ever?

Onset is likely 0 > 10 in <5 mins.

#SWPiPC

Pregnancy - can be very complex

Migraines often worse in the first 1/3, often better in 2/3.

First occurrence of aura in pregnancy is quite common due to ⬆️ esteogren.

Serious causes = preeclampsia

Compare acute BP to booking BP in pregnancy.

#SWPiPC

Over 50:

⬆️ risk of malignancy

Consider giant cell arthritis, can present as almost any type of headache.

Consider:
ESR + CRP

#SWPiPC

In the back of your mind consider carbon monoxide, thankfully very rare!

If headaches often occur in one place/building and clear in fresh air, consider CO poisoning.

Remember typical sats probes won’t help!

#SWPiPC

Exams and investigations:

- CRP
- ESR
- BP
- Ophthalmoscopy (very challenging in PC, if in doubt, refer to optician)

- MRI? Unless red flags, very little benefit.

Talking about migraines and other primary headaches.

Aura appears in 1/5 people.
Migraine can cause cravings - often sweet food!

Migraine is the most common type of headache.

#SWPiPC

Tension headaches often resolve before any appointments, if they present to you, much more likely to be a migraine.

Cluster headache

Reported by some women as worse than childbirth!

Symptoms:

- strictly unilateral
- autonomic symptoms
- 30 mins > 3 hours max
- restless or agitated

More commonly in men, but not exclusively. Most often ages 20-30.

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How do we differentiate migraine Vs cluster?

Very different, but often challenging to diagnose.

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Super quick run through on treatment and myths now from Dr Miller

Migraines myths:

- migraines don’t always have aura and vomiting
- can wake you up
- commonest cause of daily headaches
- frequent in elderly

#SWPiPC

Treatment:

Review any triggers in everyday life first.

Then, treat the acute headache
- 900mg aspirin + anti emetic
- triptans (oral, nasal, injection)

If using triptans, rotate through oral, nasal and injections of the first attempt does not work.

Cont….

Contra indicated in >65, thought now to be safe in pregnancy.

Ideally use triptans in the headache stage, not aura.

Prevention (often better than cure):

- amitriptyline, beta blocks, candesartan etc
- acupuncture
- Botox
- Occipital nerve injections

For cluster headaches:

Treatment=

- O2 @ 15l/min, usually clears a cluster headache in 10-15 mins
- Nasal triptans

Treat early and quickly.

#SWPiPC

Take home message for me from this ace presentation:

- mostly likely to be migraines
- tumours are rare 1/1000
- treat headaches early where possible

#SWPiPC