Download Serious Causes

Serious Causes
Rarely seen, but not to be missed
Warning features in the headache history that suggest a serious underlying
cause:
Headache that is new or unexpected
in an individual patient
Thunderclap headache (intense headache with abrupt or
“explosive” onset
Patients with sudden severe (thunderclap)
headache should be referred urgently when
there is a suspicion of subarachnoid
haemorrhage (SAH). Urgent out-patient
referral is rarely appropriate as the majority of
these patients require immediate
investigation (normally a CT brain scan and
lumbar puncture) to exclude SAH.
• Headache with atypical aura (duration >1
hour, or including motor weakness)
• Aura occurring for the first time in a patient
during use of combined oral contraceptives
• New onset headache in a patient older than
50 years
• New onset headache in a patient younger
than 10 years
• Persistent morning headache with nausea
• Progressive headache, worsening over weeks
or longer
• Headache associated with postural change
• New onset headache in a patient with a
history of cancer
• New onset headache in a patient with a
history of HIV infection.
Patients with other suspected serious causes of
headache should be referred for an urgent
appointment to the Neurology department.
Very urgent referrals (e.g. suspected brain
tumour referrals) should be discussed with the
Neurology Specialist Registrar on-call to
arrange an out-patient review.
Treatment of Migraine
• Acute Treatment for migraine headaches
• First line:
– high dose soluble Aspirin (900mg) combined with anti-emetic
– Diclofenac 100mg suppository
• Second line: Oral triptan (e.g. Almotriptan 12.5mg)
• Migraine prophylaxis
• First line:
– Propranolol SR 80mg od-160mg bd
– Amitriptyline 50-75mg/day
• Second line:
– Sodium Valproate 300-1000mg bd
• Topiramate 50-100mg/day
Medication-overuse Headache (MOH)
• Only treatment is withdrawal of the suspected
medication(s)
• Triptans and Non-Opioid medications can be
stopped abruptly
• Opiates, opioids and barbiturates have to be
withdrawn slowly
• Withdrawal headache can be treated in the
short-term with Naproxen 500mg bd
Referrals for Chronic Migraine
• Patients should be referred:
• If there is concern about the diagnosis
• If Migraines have not responded to adequate trial of
treatment with at least two first-line agents
• If there is continued headache despite withdrawal of
analgesics likely to be causing medication-overuse
headache
• If there is severe uncontrolled migraine lasting more
than 72 hours (status migrainosus)
• Patients should be asked to keep a headache diary and
identify trigger factors where possible.