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Good morning, everybody. Thank you for joining the core. My name's doctor recent, their neurology registrar and academic At's and George's Hospital, which is in southwest London. Um, all right, one. Start you today about one of the commonest presentations in all of medicine, something that you really need to know about it. It's incredibly common, something that effects probably a significant proportion of you, as well as a very significant portion of your patients on going to go through a whistle. Stop. Tour of Headache. This is not gonna be everything. You ever have to know that it's going to hopefully help you structure your thoughts and structure your approach so that you manage your patients safely and effectively. So probably yeah, so it's common. It's, uh, about four consultations for every 100 patients in general practice. It's up to about a quarter off a week for roles to urology specialist services. Ondas. Well, come on. Two later it and so incredibly common in the emergency department as well. Um, if you take a lot headaches together, uh, it happens to about one in two people each year. The lifetime prevalence off migraine is about 30%. So about one in three women in the world on do about one in five men. Onda Awful headaches Migraine is the most common kind of headache. There's definite migraine, and there's probable migraine, and it isn't really worth getting hung up between the two. In terms off women, women have overwhelmingly a greater burden off headache than men, and it typically affects women in their both their reproductive years. And they're economically productive years. And so it's a huge problem if the economy asshole on it could be such a disabling problem for so many women that it can buy the delay, uh, reproductive choices or on and can delay them to the point where, unfortunately, some women end up know having the families that they would want to have, because that's a debilitating by the quite. The headaches are so scared off good headache treatment because of any potential interactions for them or their baby. Um, so, uh, just to put some, um, to put some numbers on it, they're about 100,000 days of absence from work or school every day because of headache on do about 25 million lost work's work or school days every year around the world was having. So this is This is huge on do. It's important and it's common, and it's also very treatable. So I'm sure, or a least I hope that everything look, you've had someone has said how absolutely vital of the history is to the diagnosis. That is, I think, more so in urology than anywhere else, and probably more so in the headache. But other parts of neurology headache is absolutely vital. This is not a disorder that results on that, that you depend on tests. It's not a disorder. One second, it's just that, um, uh, it depends on tests on you. For the majority of patients, the examination is going to be completely normal as well. Um, on you're going to see a lot of people with headache. And actually, the typical approach of good medicine is very open questions. And only after exhausting your open questions do you start moving too. Closed questions in headache. There are a few key things that you really need to nail down. Um, Andi, until you've nailed those things down and you could be quite close to about it. Ah, that's that. Really what you need to do on, but I've put those things on here, so the the time duration is, um, is absolutely vital. Did this come on in an instant? So I'm sure you're aware of the phrase thunderclap headache. Thunderclap headache, by definition, reaches maximum content intensity. Within one minute, someone might come to you. Oh, this is a really bad headache, and it came on really quickly. But what I mean it is over the course of half and hour to an hour and a half. There have a got steadily worse. That's not a thunderclap. Headache might be really severe, but it's no thunderclap. Um, how long does it last for Will come on to be at the diagnosis of the diagnostic criteria from migraine in a minute. But for isn't migraine typically has a duration of more than four hours up to 24 or 48 hours, whereas the family off had a disorders called the trigeminal autonomic Careful Alger's or the tax. They distinguish themselves between each other based on the duration of the headache from seconds two minutes to hours or constant, um, on. So how bad is it? And unfortunately, there is no good gauge of pain. It is the one purely subjective experience here in the world on we generally do a pretty crappy job of understanding that suffering the patients go through. But we need to quantify it. Something fell because quantification helps with tracking and helps with understanding eso. Typically, I say, I want you to tell me how bad your headache years on the north to 10 scale where nor did you have absolutely no pain at all. And 10 out of 10 is the worst pain you could ever imagine in the whole world. Worse than childbirth. Worse than anything that you could ever imagine. And even then I get people sat very common. Oh, yeah, it's probably a 10 out of 10. Okay, How bad is it now? Yes, 10. And you're thinking, How could it be? 10 out of 10 pain, the worst pain you could ever imagine. It was out here in a loud, brightly lit emergency department, and you're having a nice on track with me. But it is worth nailing down because different headache types typically have different levels of pain. Um, on also, if a patient says it's eight out of 10 in the beginning and several months down the line after a period of treatment. Well, I'm still getting the headaches, but they're only three or four out of $10. Then you can say, Well, that's that's success we've done well for you on then. You really want to get the quality of the headache on. But, uh, unlike with, I do ask open questions. But I limit the amount of time that goes into it because people are often very good at talking about their headaches for a long time. And I say things like people often use words such a throbbing, stabbing or aching more, uh, kind of flat will squeezing to describe the headaches. Which of those sounds most familiar to you on that helps you if that helps you discern what the nature of the character of the headaches and then you want to find out if they're a headache person in North Person who turns out 8 58 who's never have a headache in their life, is very different from the 32 year old who's had headaches one of her life on D. Ben, You need to try and tease out why have you come today? on, then there are some things that are that are linked probably genetically, with headaches. So some women get really bad headaches, always around the same time of the mental cycle every month. Um, some people get if they drink alcohol, get really, really bad, hangover it and feel awful the next day. And it's primarily the headache that drives that. Some people, uh, you can drink very heavily, and they don't get headaches the next day. The kind of people that get hangovers are also the kind of people that feel very travels it. They certainly couldn't imagine sitting in the passenger seat of a car reading because that really just turned their stomach. They often get quite heavy Cuban. They get hungry and then they can eat something on. There were also helps you to, uh, put our other triggers, which could be caffeine. It could be sleep deprivation. You can explore that with them. Some people have very clear food triggers to their headaches on. That's just a way that if you are, if you identify it, you can, um you can help themselves managed the headaches. Um, so there are certain bits of the headache that are very, very important for you to, uh, for you to mail them. So the migrainous features are photophobia sit us dislike of bright lights. So typically, any hospital environment phonophobia That's dislike of noises. Eso if they got brought in by by ambulance, How like what happened in the back of the ambulance? Got there. Did the sirens make it worse being in the in the emergency department Now, is that making much worse? Or eczema phobias? This like of strong smells? And I imagine if you're in in the emergency department and you've got a really bad migraine and you've got all the alarms going off and you got all the commotion oven, any department the person next to you have severe diarrhea on and you've got these horrible right halogen lights above you that's going to be the worst possible environment. And typically people with migraine say, I'm gonna have a migraine. I want to go to my room. I want to lie down in bed, pull the curtains, have it nice and cool, dark, and I want to do nothing. Whereas someone with a cluster headache, they will not be able to sit down. They are restless people can actually give themselves head trauma because then bang their head against the literally banging their head against the wall to try and get rid of this headache. People have even called cluster headache Suicide heavy before it's that bad. Um, you So we talked about migraine. It's features. The nausea and vomiting are incredibly common and need to be asked for because that part of their part of the diagnostic criteria um, some headaches get better with lying down. Some a headaches get worse with lying down, and we're gonna come onto red flags in a minute, but had aches that wake you up. We'll get worse when you lie down, get worse when you cough or sneeze or strain, or even if you're having sex. That valsalva maneuver, uh, can really exacerbate a headache on. Do you need to get over any prudishness of shyness you have. You need to ask about the effect of sex on headaches because of lots of people have severe thunder, clap headaches, even during sex on. Do you need to ask that because people were very rarely volunteer it, but that can help you give specific headache times and make their lives better, um, and then autonomic features. And this will take you off that you're looking at one of them. As I said, every other trigeminal autonomic careful. Alger's eso, as the name implies there, trigeminal there, mediated on the trigeminal nerve. There's a lot of facial pain associated with their their autonomic, so you get signs of autonomic dysfunction. So typically, one eye is terror. One knows, or one nostril is, um, swollen. You might get a nasal drip just from one side. You might have just half your mouth feeling very dry. You might have flushing just on one side of your face, and all of those signs be on the same side. And if the same side every time on, that's telling you that it's a trigeminal, well tonic water, and then you go back to their to the duration and the onset to try and figure out which one of these it is someone absolutely vital. Better. The history is finding out what they take, not just what they've been prescribed, but everything that they take what the over over the counter medications that they're taking for the headache, how also, they taken it in an average month. How many days? Or in an average week? How many days a week? Would you take any kind of pain medication that any kind of pay, not just your headache on? We're going to, um, we're going to come on to thinking about something called medication Overuse. Headache that will potentially really makes a management of getting rid of these headaches for your patients much harder. And then you need to examine you. Uh, you need to do it for neurological examination, but you will still need to look at their vital signs. They hypertensive. Are they tachycardia? Fever? It's incredibly important, and obviously any rashes that might, ah, that my indicate a very, very worrying kind of headache. Million chocolate septicemia. You're unlikely to miss that because you've got a really Syncopation to want to be, um, and then one thing you absolutely have to get used to, and I know this isn't topically. When you came medical school was, I hope it's talk better in Ukrainian medical schools is getting used to looking in the back of somebody's eye because that the philosopher's always say that their eyes, the window to the soul. It's certainly the window to the brain, and it's certainly the window to intracranial pressure on. So you have to look and you have to get used to look in the back of people's eyes. Even if they have photophobia, you need to look in the back of their eyes because that will tell you about all kinds of internal pathology. It will also tell you about some kind of ocular pathology that can masquerade as headache. I just want Teo talk about the difference between nuchal rigidity and back tenderness. Anybody that has a headache will have a a sore neck. And if you press the neck, that is, if you press hard on your neck, that's not particularly comfortable. And I've got some shoulder pain at the moment, So pressing on my neck gives me a bit of a headache. That's not the same as nuclear rigidity, where you ask someone to bend for chin towards the neck. And it's it's no lateral movement like that or like that. It's the anterior posterior neck flexion extension that stretches them in in geez on that causes severe pain. So don't just put the back of them. They're concerned about her because the answer is almost always, yes, Get them to touch the chin to the chest. Look up. What Kernig's from Bridge since he's science are because that will help you find signs of meninges. Um, not necessarily meningitis, but meninges, Um, and then in an older person. So anyone over 55 presents with headache, particularly if it's a new headache. You want to be feeling documenting whether there's any tenderness off the temporal artery on the triggers. For those of you, don't remember your ENT and actually very well is the little kind of normally bit just a front of the ear hole. That's the triggers. And if you have, the temporal artery starts to wrap around the front of the skull there. But it starts there to start there and then just work with your fingers palpating along feeling for any tender or thickened part of the temporal artery on whether it's a normal pulsation. So you will be able to feel your temporal temporal pulse by putting your finger just in front of your trace. Now it just break for half a second, then it sometimes even easier than finding the Arctic, their radio pulse finding the tracheal were there with the temporal pulse. Um, in any patient with the new headache over 55 you have to send blood tests for s are CRP and fbc. Um, about AzaSite. Headache isn't really, uh, an area of medicine way you need to send lots of tests. Okay, Sorry. So when do you need to worry? Well, with every patient you need, Snoopy. But signs of secondary headaches on this acronym, Snoop four has been set up to help you remember what the signs of secondary headaches up. So the first s is for systemic symptoms. So has there been any weight loss or fever? Um, uh, or night sweats and then secondary risk factors. So things that might predispose predispose them to non ST secondary headaches So they immuno suppressed in any way. Or are they taking toxic medicines for for underlying conditions? So things like HIV, whether it's diagnosed or not, uh, TB cancer. And that isn't just the immune suppression of malignancy. That's also the medication that they they've been given on. That's was historic cancer. So things like, well tolerated sore on him, a attic stem cell transplantation that may have happened many years ago, but you're still on immunosuppression therapy for that on go inflammatory conditions like polymyalgia rheumatic. Oh, any of the rheumatological conditions that immunosuppressive by that because of the that clinic inflammation that you have because the condition or either general, very specific and, you know, suppression that's given to treat the condition. So that's the ass. And is 18 urological symptoms or signs other than hey. So if they've got double vision, that's a worry. Anything. If they've gotten numbness or weakness, that's a very worrying thing. If they have pain moving, they're Irish. They haven't injected red eye. That is difficult to move, unlike the injected I ever at one of the tanks. Um, that's something that made you think I need to be much more worried that this is a secondary headaches, sudden onset of thunderclap headache. In Just to reiterate, that means had a concept within maximal intensity within one minute onset. Um, that's standard. And then, as I mentioned a few times already, the older patient with a new kind of headache on by old it's kind of more than 50 or 55. So I'm not particularly old that you don't really get you don't really get Uh huh uh, giant cell arteritis under 50 but also over 50. You've got a much greater likelihood epidemiologically off other conditions like cancers. Be that intracranial cancers or or systemic cancers that might predispose you to secondary headaches. And then it's snoop four. There are four things beginning with P. So you look for papilledema. And if you find papilledema, that is a course of concern, and you stop and you figure out exactly what's going on and your image pulsatile tinnitus. So what? That is it. That's a symptom that's relatively specific for a condition called idiopathic intracranial hypertension. It used to be called benign intracranial hypertension, but it can make you blind s. So if you have an overweight, typically young woman who has headache when they lie down, um and they say they hear like a, uh all the time in their air, especially if they bend down to tie that shoe laces or something like that. Or it might be more tinnitus, So high pitch sound. But but with a pulse, it'll quality to it. That suggests that there's raised intracranial pressure that might be idiopathic, but you can only say it to the A Patrick with the know it's not something like a venous honest on basis or a tumor causing raise pressure, he for positional provocation. So we've talked about high pressure headaches being worse with valsalva maneuvers and lying down. You want to get low pressure headaches. So that's typically where there's been a tack or a puncture of jurors at some point, causing CSF to recount, causing the brain to sack down on Ben. I'm fine if I, like, lay down. But any time I stand up, I've got about a minute or two and then this head it really comes on, and I can't I just can't get to work anymore because I can't stand up and I can't commute to work soon as I'm lying down on. Fine. Um uh, so, yeah, uh, low pressure headaches we've just spoken about and their headaches precipitated by exercise. And as I mentioned earlier, that can include in school. So what are the secondary headaches of these? The ones that will kill your patient or a least Make them go blind if you don't do anything about it. So just going round anti clockwise. We've got an intracranial mass lesion tumor. Usually that or possibly an abscess that would lead to raise internal pressure on day so you'll get the symptoms that we've discussed worse on lying down worse from coughing, sneezing. There may be a fever with it. If it's an abscess. Giant cell, it's writers. This would be an older person that we're also say things like They get a pain in the draw. They get tired in their door when they, when they're chewing on day, have to. They have a few bites of something in the menu to rest that drug because it starts to ache. And that's literally it's skinnier of the muscles drawer because of the because of the vasculitis Association on acute angle Closure glaucoma. Again, this is more from a logical issue, but it can present this headache typically in the emergency department problem, not side poisoning Is something really frequently overlooked? Um, Andi, uh, that's because it's very difficult to pin something down to carbon monoxide poisoning. The test that will really help you is an arterial or even, uh, venous blood gas. But just frequently done in the emergency department release, it is where I've worked in the past uh, but you need to think about it on D in different parts of the world, especially unfortunately, in places that have a huge destruction to their infrastructure. There. People burning on solid fuels indoors can lead to carbon monoxide poisoning, and it's very general generic symptoms good that include headache and drowsiness. If you look for it, you can a stop the patient going home because then they will go home, and then they die. But also you can treat it depending on help how severe it is. A systemic hypertension could lead to a hypertensive encephalopathy. There's a condition called posterior reversible and careful Opathy syndrome that can present with headache and seizures are not on visual problems, because you get these in Catholic changes and often in the occipital lobe, which is why it's called posterior reversible, but even just severe hypertension. So in blood pressure over about two hundred's millimeters symmetry to stop, it could lead to a hypertensive. Been careful? Yeah, arterial dissections. So anytime, get a painful orders syndrome, so toast It's my own, sits on my dresses and headache. That's a carotid artery dissection until proven otherwise. So you need to do a CT angiography and then things that you will probably think about meningitis or encephalitis. Headache with focal neurological dysfunction or altered state of awareness and fever. Cerebral venous science from basis. That good in the news big time in the last couple of years because they were very small number of patients that got a vaccine associate being a Sinus from basis. In fact, I looked after a young femur actress who ended up needing a craniectomy to relieve the pressure in her head because of the fact even juice from both sides. Uh, Subrata hemorrhage. So this is severe underclass. Have a quarter of people die before that significant attention? Or in what people die immediately about people dying hospital on 50% of people survive, but it's severe neurological on. Explain your high potential for so those are the secondary headaches, and you absolutely need to know that you absolutely need to call them out in in every single patient. I'm just going to reopen the trap, Uh, because I just got another network and stable warning on it, so hopefully that plane to breakfast anymore. But please let me know. It does so when she ruled out the secondary headaches. Then you're left with the primary, and this is overwhelmingly likely what any given patient in front of me? Um, the secondary had explored Ran, but they can't. The primary headaches are common, but a cause of a lot of morbidity. They don't cause mortality. Although, as I've said, cluster headache has been called suicide heavy because it's so bad that people have taken their own life to avoid the pain. Um uh, And if you do it right, first time, then not only do you make your patient better, but you also make yourself better because otherwise they keep coming back. I'm not going to go through this whole flow chart, but this is from the eye. CHF. The international classification of headache disorders. The third direction of it on this is a very large volume that no one expects you to remember. Even having specialists don't remember every inclusion, exclusion criteria of every one of these. But these are the primary. You break them down into time, so if they last more than four hours, then it's one of these. It's migraine, which is overwhelmed. It's common tension type headache. Some people, a lot of people would argue, but that's huge. Degree of pathophysiology call and political. Who's a lap between migraine and tension, the new daily, persistent headache. And just to give you 11 line of each of those. This is someone who says, On the third of February, we'll have it started and it's now 3/8 of October and I know exactly what I was doing. I was walking in the park in the third of February 11 15, and this headache started and it's never gone. People are incredibly specific about the moment that it started. Sometimes it if it's if it's anything more than a day. Oh, sometime sometime a few months ago, then it's not new daily. Persistent Head. If it was, it was on this day, then it may well be on that needs to have lasted more than three months. And then this thing called Hemicrania continual, which is where I had a headache that hasn't never gone away only affects more right only affects the left side of my head on. It's they're consistently, um, and then, with all of these people, self medicate people don't often go to the doctor. But hey, there's a far greater burden of headache in the community never beats medical attention. But people often take the wrong things or day for right things. But fighting often leading to a different kind of headache or medication. Overuse, headache then they're the trigeminal was not like the allergies we have spoken about. So sunk eso sh sure your unilateral, uh, sorry, I'm pulling a blank. Um, what some stands for a moment, but they're sunk. And a very similar slightly different feeling cycle sooner paroxysmal hemicrania, which is half my head really hurts. And I get tearing an injection of my my right of one I get streaming out my nose hard for my mouth feels dry, but it lasts quite a long time sooner and sucked are incredibly short. Yeah, thank you very much. The short lasting unilateral neurologist for my headaches, Um, either with chondroitin type of injection, tearing that sun or with autonomic symptoms that sooner, um on then, cluster headache, which is lasts usually kind of less than about an hour. But more than a few minutes on some people includes trigeminal neuralgia in this Well, um and then there The other primary headache said these are even rarer, um, that it's worth being aware of thumb your condition called stabbing Headache. People say it feels like something's just putting a drill straight into my head, and it hurts here, numb your headache s. So that means circular headache that they say It's like a patch of just got this round patch on my head That always hurts sex. Headache does work since Tim, and it can really ruin people's lives and, uh, reblood choices and on and really impact on on their quality of life. And it can make people very, uh, restrict that that, uh, social life and everything else on diets difficult because people they often like to talk about it. But you can really make someone's life better by asking about it. Been treating it, uh, cold stimulus, headache, everyone. If they jump into a call, Blake will get a headache. But some people don't need to Such a a severe stimulus is that on Hypnic headaches, something that repeatedly weights and wakes somebody from sleep Primary thunderclap headache. So this is a standard true thunderclap headache, but not necessary. But But one way you've excluded other causes of thunderclap headache, and I'm gonna come on. Actually. So, migraine, I've said over and over again, I'll continue to say is very is the most common. So this is a headache that lasts at least four hours, and I could often last up to about seven days. And it's usually it needs to have two of these. And one of these, um, which means that it know one of these headache. Uh uh, descriptors is either necessary or sufficient, so you will have different people. Have headache, who have migraines that have different but describe it very differently. So it's usually it's one. It's a one sided headache, often behind the eye. Uh huh. It's pulsating or throbbing, and it's moderate or severe. So this isn't something that this is something that you definitely notice and will ruin your day, or possibly even days. It is made worse by or exacerbated or even stopped you getting on with your normal activity. This is someone who wants to lie down in a cool, dark room with no noise and no light. During the headache, people get nausea from it and often have photophobia phonophobia and I really, I always ask about osmophobia as well, so just like in strong smells. So if someone has a bilateral fairly flat headache, but it is moderate or severe stops and doing what they want to do been not so great if it is, uh, only natural, Um, and strobing, it is not particularly bad. Ah, so they would probably say, My old so kind of up to about four and not to 10 scale. Ah, and they're able to carry on with their day, even though it's not comfortable. Technically, that wouldn't can't as a migraine, but you would call it a probable migraine. And this is why, um, and the reason why it matters is because you can then get good treatments for and depending on how frequent migraines are, you could either choose just in abortive treatment, or you could choose a preventive treatment or both. And you can make sure people on developing medication, nausea and vomiting is so frequent that it's worth giving a prokinetic antiemetics or something like pro. Uh um, something I metoclopramide or don paradigm, because know what I need is your head standstill when you're having a headache, your stomach sensitive as well. So anything but you're taking to get rid of the headache just sits in your stomach and the stomach doesn't empty. So if you give a prokinetic anti emetic, nor really does that take the nausea and vomiting away? It also gets the medication that you're taking for the headache out of the stomach and into the small bowel, where it can get absorbed and do something. About a third of people who have had migrate have aura, the most common of which is visual aura, which is zigzags or scatomas or fortification spectra that they have in their vision, often around the edge of the vision. But it isn't only visual aura. Uh, you can get other complains of war well on that matters, because having migraine with aura significantly increases your risk of stroke on. That's why people who are young women who have migraine aura are told. I I'm not recommended to be in a combined or a lot introspective pill because that further increases your risk off from both cysts on. It's a matter off off trying to reduce that risk. So I've sent the bottom migrainous feature for Hey, this isn't something that's flat, boring and kind of you don't notice this is something. I have a whole load of things. That's where it's gonna bring a day. Uh, so in the, uh, sorry. So we've talked about triggers already on I almost always ask patients miss with headache to keep a diary on on the diary. It could just be a simple pen page of paper. Um, on any given day, did you have a headache out of 10? How bad was it? At its worst. What did you take for it, then? Over time, you can then pratense that things like menstrual periods. And then you start seeing patterns emerging. Over a few months, you start noticing. Oh, well, always. When I had cheese late at night, that was something that definitely give me a headache. All if I drink this particular kind of alcohol, I get headaches, drink other kinds of alcohol. No alcohol at all, like daycare, headaches, and then people you can just say to people Well, avoid those things as best as you can. That might be well, the treatment Well, you're going to give him a drug treatment on drug treatments. Are you start simple things like paracetamol, nonsteroidal anti inflammatories. So that could be ibuprofen. Or it could be something stronger, like a naproxen, Um, or, uh or even high dose aspirins in 900 mg of aspirin. That strong a solution works very well as an abortive treatment, especially in people who have contraindications to triptan tripped and usually the best medications in association. Paracetamol, onda prokinetic anti emetic. But if they're having more than five headache days a month, so that's on average a little bit more than one a week, then you want to stop them. Getting the headaches in the first place on the trick with this is to start low and increase slowly, because if you give them lots of side of extra minute know to stop taking it, and you've got to tell them that you're not gonna promise them a cure. And in all the trials for preventive treatments from migraine, the the primary endpoint is a reduction by 50% in severity or frequency after three months. So the worst thing you can do is say go and take some propranolol and you'll be better tomorrow. Work. Don't have any more headaches because then they'll have a headache next week on do they, uh, and then they'll just give up on their off on the treatment. You suggest that doesn't work, so you really have to manage people's expectations. Someone's just asked which prokinetic is better done. Paradigm that's close for made. It doesn't really matter. Thereabouts is good as each other. Uh, often it comes down to What's the date? Uh, what's cheaper, depending on the health system that you are, I'm so after three months, you want to know that if they were having two headaches a week, so that's about a headache days a month. You've got that down to four headache days a month. No Izzy row, but four or they were all tenants attended there, now gotten down to about five or six out of 10. That success on. Then you can help them by into get them to carry on taking it, and it will continue to be a more effective and over time you're just instead of, um, instead of having esque steering a nice, nimble jet ski, you're turning a big boil tank around in the C is going to take a long time, but you will get there. One important thing I want to say now and you should say this like a mantra is that you never, ever, ever, ever, ever, ever, ever given Opiate based on allergic to somebody with headache know, lonely. Do they work? Very well. If you're much more likely to develop medication, overuse, headaches with opiates and that includes things like codeine or cocoa tamal. Um, Andi, uh, if you develop medication, overuse, headache with codeine based I'm sorry. With an opiate based pain killer, you're much less likely to get rid of that medication. You said a on then they're really in people because they've got this. It's really difficult to treat mixed, have a type. But the best method is therefore, to avoid getting into that situation the first place. And so promise yourself now that for the rest of your career you will never give any kind of opiate for any kind of headache. Ever, ever, ever. So if they're having more than five headache days a month, then in this country, the guidelines suggest offered by the to pyromaniac propranolol. But there are other options, and then, as people sale one treatment, which is incredibly common, then you can try other treatments. If you start propranolol or you could go to two pi remain. If neither of those work, then you could try amitriptyline. Riboflavin is quite difficult to prescribe in the UK, but you can alter it. But you could encourage people to buy it if the counter and then you're moving away from tablets and you're looking at what July and, um, toxin. But in this country, you need to have their not responded to three different prophylactics in the past. So that's that's pretty much a year of treatment, of different kinds of things on. They're not having medication overuse. And then this is my headaches. Quite exciting area of medicine. You've now got the monoclonal counting related gene peptides CGRP agonists that that are absolutely incredible at stopping migraine. But again, they're new. Therefore, they're expensive. Therefore, they that difficult to prescribe least in this country back just a quick aside giving time. I was on holiday of it sitting family in America, and I've got talking to someone at the side of sewing pool, and I said that was a urologist and they said, Oh, this new drug. She was on the Jovi, which is for a minute from another imagistic. I couldn't work for months or even years because of my migraines. And then I started this drug. I haven't had a single migraine since. It's absolutely changed my life. You could see she was beaming from into here. And that's the, uh, that's the the effect that good migraine treatment can happen. Somebody, um, these are all the different kinds off off preventive options that could be used in migraine. So there are lots of choices and ideally, what we want to do, what you want to look at other co morbidity. So it's sort somebody. They had quite a lot of anxiety in her life until I chose propranolol is a good migraine preventive for her in somebody who's very overweight. You can try to prior make because it does have a side effect off reducing appetite that in there for me to wait, Loss doc and never will need to beneficial effects on headache. Part of it is also used in idiopathic. You trained crime potential partly for the weight loss issue, where weight loss is the single most effective treatment from it for idiopathic entry or hypertension. But also it has a mild carbonic anhydrase inhibiting effect which, like on Diamox, which reduces CSF production. Conversely, if someone is quite overweight, you probably wouldn't want to try about. You certainly wouldn't want to try the outbreak. There are women of childbearing age because it it's teratogenic. I'm not going to go into bees in detail, so the time is 9 45. I think I will quickly took that cluster headache, but I kind of covered all of it's already so it's an absolutely severe headache. It will make you want to enter life. It is strictly one sided. It's usually around here on. It lasts anywhere from a quarter of an hour, three hours Onda. It comes really frequently, so my only be 15 minutes of wanting to end your life. But that might happen eight times a day, and it goes through periods, so you'll have a spate of weeks or possibly months of really, really frequent, even mind faltering headaches. And then, um, it will subside for a few months and you think you're clear of it. But then it will come back, and these are there these the associated trigeminal symptoms that I speak about, But, uh, what do you do for cluster headache. Hopefully, many of you would have heard of giving high flow oxygen, so that will be 15 liters a minute of oxygen with the number of breathe mask on. Don't really know how that works, but it does. People therefore need to have an extra cylinder nearby, which is fine if you're a home. But if you're a park or if you're upset, um, or whatever else on one of these kick off, then you're really trouble. But actually, a trip down can also work well, Um ah, so they as a safety need to have oxygen available with him. There's often heart, and especially if the last couple of years, with huge demands on oxygen because of Cove it. A lot of people have really suffered. If it's happening frequently, they want to give prophylaxis. For verapamil is probably got the best evidence that there is, but this is the kind of thing that you should be referring to. A headache specialist or least a neurologist before starting. Oh, when I say triptan is work, it's no oral seem a triptan. It needs to be a nasal or subcutaneous version and a lot of other things that you're used to giving Just don't work fare Migraine story for cluster on. Let me just reiterate it. Because if you only remember, one thing from this hour is that you must never, ever, ever, ever, ever, ever, ever prescribe any kind of okay for any kind of headache ever in the rest of your life. So help you got, I hope I've dropped down enough. Um, and if it isn't, as I mentioned earlier, if it isn't about 15 minutes to a couple of hours, if it's like the much, much shorter, much, much longer, then it's going to be one of these other conditions. Medication overuse, headache abortive. Spoken about If you're taking paracetamol, so that's acetaminophen. If you use the American terminology or non steroidals ibuprofen more than kind of one in 2 to 123 days, then you're like fate. For your headache, you're likely to develop that you'd it's need even less so. You really need to use a times a month for a triptan, and you only need to really be using konia or an opiate based on Allergies X, And that would include tramadol, morphine, oxycodone, OxyContin, any of those. If you're using that more than about once a week to your headache, you're likely to develop medication. Overuse. Um, you need to really, really ran home that they should only be taking pain. Killers. Where? Headaches. Two days a week. If they're needing it more than that, they should be on a preventive therapy. Uh, said it before I say it again. Never use opiates on on. That includes a lot of over the counter preparations in this country is quite hard to get hold of opiates. But actually, if you look at a lot of be over the counter painkillers targeting the migraine population, then a lot of them have codeine in it. Um, so in one large hospital in the UK So I'm going to skip this. If a patient comes in with a thunderclap headaches, CT finds a suburb still know opioids what you treat with you. Don't you refer them to the neuro surgeons on. They can treat the headache. I'm assuming that almost nobody on this court is going to become a neurologist. A neurosurgeon. So different rules apply. If you are a specialist, uh, assumes you find a summary of hemorrhage, you refer to the neurosurgeon because otherwise your patient has likely to die. Will have very poor urological alkums. Um, I just want to talk about supper at night, very briefly, given that it's nine minutes to, um so everyone thinks about thunderclap headache equal supper at night. What? Actually, only 10 to 25% of true thunderclap headaches are suffering Hamburg. And that means that between 75 90% of thunderclap headaches or something else when we're going to come on slight in a minute. Because this is, I think, important for you to know. The first thing you have to do when you think it might be a subject of hemorrhage is a CT scan. But if you've left it more than about today, the chance of you picking up a submarine or hemorrhages very lucky if you get it in the first six hours on the CT scan is reviewed by an expert neuro radiologist, your chance of missing some bromide is incredibly small, not zero. Uh, but if they've come after a few days and they it's now, Wednesday and on Sunday I had a headache that was like that. It felt like two came behind me and smacked me in the back of the head of spayed. That was on Sunday. I didn't want to come to hospital because I was worried about Kobe it, and now it's Wednesday. You need to do the CT scan, but you can't reassure the patient that they haven't had a supper at night. If the CT is normal, if you catch them within six hours, you're not sure if the CT scan has satisfactorily excluded Xanthochromia. Then don't do an LP immediately. Keep mental hospital the following day. Do the lumbar puncture looking. Present the Crimea and make sure that their sample is hidden from light. So as soon as you get the CSF out, put it in a in an envelope or or put it in a bag while you take it to get a burn tree, because light will break down xanthochromia. And I'm not going to talk about the management. It's abiraterone a time, but I do want to just look at this light briefly before taking restaurants. So, uh, one second. Sorry. Um, intracranial hemorrhage often causes severe headache, and it could be very rapid onset, but you will pick that up. No, Excuse me, don't contrast, CT uh, scheme extreme can very rarely cause, um, thunderclap headache. Scheming streaks are almost always, by definition, loss of function and headache is gaining function. Arterial dissection. As I've said, a painful Horner's would be, uh, it would be a, uh, you need to exclude carotid artery dissection when you need to do that with either a CT or an MRI and geography of the neck vessels. A venous Sinus term basis. You'll need a venogram either again, either CT. Where are we on We'll also called raised in training pressure, which is why you do along the country. Meningitis causes race pressure, and so you need the lumber puncture, and then you're looking for a passel cells low glucose on the manager to these are different talk, spontaneous in training or hypotension. There are some very useful Emory markers that the person who reports your MRI needs to know what your what they're looking for because there are some specific measurements they could take. You need to do an LP to prove that hypothesis to prove that the opening pressure is very, very low, and sometimes you don't actually get an opening pressure because there isn't enough CSF, where there isn't enough pressure driving the CS that up the manometer pituitary apoplexy. Um, you need to think airflow for and you need to speak to your radiologist to look at. In particular, you may need an emery you made also need to send pituitary hormones on the blood blood test. Someone who's got incredibly high BP can have a thunderclap headache. Need to look in the back of their eyes. And you need to document that BP often in doing in both arms, just in case they're hypertension is caused by pathology of me. What you got? Um, Giants arthritis? I'd mentioned already. A third ventricle. Colloid cyst. This is something that you'll pick up on imagery so long as you're thinking about it. It's a headache that could be very sudden onset, but also very sudden offset and basically what it is. It's assist sitting in the eventual temporarily block the formula and the the outflows off the third ventricle, leading to very suddenly very severe rise and pressure, and that can kill people on. Do you need to see it? And if you find it, you need to speak to a neurosurgeon, Steptoe to deal with that. It's different from an arachnoid cyst, which is quite common, and it's never cause any problems on. Then there's this thing called reversible cerebral Vasoconstriction syndrome, which is where you get recurrent thunderclap headache. You're know, getting any of the ah, these patients are in often severe pain, but then it gets better. And then they come back a few weeks later and they had another one and then another one, then another one. And often if you image them at the right time, you see a construction of the vessels with angiography. Uh, someone has Austin malignancy. Yes, absolutely. It's a secondary. Have a cut, something that will kill your patient on their four. Uh, if you on their four. It is a secondary headaches, but militancy doesn't tend to cause Sunday. Clap. Headache, uh, but will cause raised in train your pressure. So based intracranial pressure Symptoms are headache that's worse. Lying flat or wakes you up. You get nausea and vomiting. Visual obscuration. So the lady I saw yesterday that had visual observations from walking along and then suddenly it's like my eyes are closed just for a couple of seconds, although I know they're not close. I just can't see anything at all is often worse with bending down hospital tinnitus as opposed to just a flat, featureless tinnitus that can happen after you go to a loud music venue. Um, uh, somebody has just passed about the safety of the patients suffering during CT as increased intracranial pressure makes the CT and see. So a CT is a very quick I/O of a scanner for a noncontrast CT. They're lying horizontal for maybe a minute and a half, Um, on. But, uh, don't don't worry about that. It more important that you do the CT scan and if you think it's a subarachnoid, then if then worrying that they had it going to be able bit worse. Uh, and there you won't significantly affect the internal pressure to, uh, to a degree, that would be worrying as abortively a day thing. I've got time to go through headaches due to raise pressure, but if you think there might be raised pressure, you need to image them. If the CT is normal, then you need to do MRI on. You need to be looked considering looking at the vessels so that both the arteries and veins not only if they're intracranial vessels, bottles of them back vessels on, but if they are no imminent risk of koning, then you need to do a number puncture as well to measure the pressure, but also to treat it by reducing the pressure, especially in the case of idiopathic intracranial hyper tension. Um, so I think I'm gonna have to leave it there for time. Just flicking through these, you'll see that there are other things that you need to think about. Giving the brain tumors would be asked about. Brenda was a rare There are very, very rare cause headache, um on you expect other signs, even if that's only papilledema. But it's one of the things that patients are overwhelmingly worried about. I've got a headache. Gosh, it must mean I've got a brain tumor. Uh, so, uh, as a last like it, it's common. The overwhelming most common is migraine. Other kinds of primary headache are more common than secondary headaches. They will kill your patient, but they'll make your patient's life miserable. But the secondary headaches need to be ruled out first because they work in your do a focused examination. Make sure you're not missing from the oscopy snoop. Four red flags. Remember that. Sleep for pneumonic, um, dangers. Turn your headache away with the Tekturna patient way with headache. Give them an actual diagnosis because with the actual diagnosis will be able to properly manage them. Um, so, uh, it is now 10 o'clock. I can probably answer one or two questions that before either your energy or my computer battery runs out. So if there's any burning questions, feel free to buy the unused yourself or ah, or question. I'm someone, um, message me saying if a patient who's been diagnosed with recurrent migraine is relieved by high amounts of caffeine, such a Zen urgy drinks. What could be done for this patient? Um so often caffeine is a trigger rather reliever, but it can be a reliever. I personally have caffeine withdrawal headaches on, and I need to go and make myself coffee shortly. But if that works for them, fine. But it might be more healthy for them in the longer term, to have a preventive therapy if they're having I mean, if you're taking six or seven Red Bull a day and some Coke and some coffee. Probably not doing your teeth for all the rest of your body. Much good. And maybe if there are you kind of look up at the comorbidity is the patient. I haven't starts of migraine preventive therapy that's been through trials, because I don't think breath blow or copal Cassie has got that letter probably has more negative effects, but lifestyle management is a key part. Off had aches, management, and you can get away with not giving drugs to a lot of your patients. Sorry, I'm just plugging my computer in before so listening to your age and listening what works and what doesn't work is an important thing today. How would you different headache and dizziness? Our med. The art stuff matters. Listen to the patient. Dizziness is another talk all together. The word dizzy comes from the old English word meaning stupid on. So if you just accept the word except a history of dizziness without exploring what it means, it's you that street, but not the patients. I'm not having you on it. I say that to everybody. Onda Um uh, the reason I say that it's people who use the word dizzy to mean all kinds of different things, and you need to drill down. Do you mean you have a sensation of movement when you're not moving that vertigo? Some people say the world spins around. Some people say it feels like I'm doing rolling police. That's a vertigo. Some people say they feel unbalanced like they're on the ship. And I always say, If someone complains of dizziness, do you mean you feel movement when you know you're not moving? Oh, the world is sitting around you. What do you feel like? You're unbalanced like you're on a share. Would you feel lightheaded? Um, what do you mean something else? And I've had people use every kind of, uh, every kind of symptom is dizziness. One person said, Oh, I feel dizzy. What do you mean by dizzy? Because people bloody like Like I said, my heart think it's an old owner and none of those my hands shaking. So never never accept the word dizziness without really getting into getting into it. More in more detail, Um, people with syncope with vertigo or that's just different from headache. It's like What's the difference between chest pain and breathlessness Sometimes they overlap, but they have very different causes. What what I mean by emotional headache? I don't think I've used the word emotional headache, a tool I I've talked about. And I'm just addressing things that I see on the chat here. I've talked about cluster headache being referred to a suicide headache on that there. That is kind of referring to just how severe the pain is for people who suffer from cluster headache. How does tremendous amount of work? I will let you look that up, but it, um it's come the COPD and cyclists basically come from a greater understanding. But we now have for the pattern biology of headache on CGRP. Calcium related Jeep peptide is an important molecule in the neural transmission of pain. And so it blocks that, um, in in two sentences. There's your answer back. Any more questions, doctor? Is I'd hope we haven't made you too late for work. Thank you for giving up your time. That's very, very bad. That wonderful lecture. So thank you very much for organizing that, and it really is a privilege for me to be able to give these to give these talks. I think I've got another one in a few weeks. She's also do give didn't give feedback. It means a huge amount to all of us that get the talks to have the the back so that we could make you to walk better eso Please, please please give some feedback of it's being a very new So it hasn't been a venues. Please give some feedback because we want it to be abused. With that, I will stop showing my screams and leave the cool on where she worked. Very, very best, and know that Ukraine is a lot of our minds and hearts.