The video version of this podcast can be found here:

·      https://youtu.be/GelDVWruIlA

The link to the video on updated migraine management can be found here:

·      https://youtu.be/LumBxN-yFmI

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the updated NICE recommendations on the diagnosis and management of cluster headaches, focusing on those that are relevant to Primary Care only. It is based on the clinical guideline on headaches in over 12s: diagnosis and management [CG150].

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The updated clinical guideline Headaches in over 12s: diagnosis and management [CG150] can be found here:

·      https://www.nice.org.uk/guidance/cg150

The MHRA advice on the use of topiramate can be found here:

·      https://www.gov.uk/drug-safety-update/topiramate-topamax-introduction-of-new-safety-measures-including-a-pregnancy-prevention-programme

The NICE recommendations organised by site of cancer on the guideline Suspected cancer: recognition and referral can be found here:

·      https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer#brain-and-central-nervous-system-cancers 

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll I go through the updated NICE recommendations on the diagnosis and management of cluster headache, focusing on what is relevant in Primary Care only. It is based on the NICE guideline on headaches or CG150 and the link to it is in the episode description.

Right, let’s jump into it.

Cluster headaches are a primary headache disorder. Let’s remember that we classify headache disorders as either primary or secondary. The cause of primary headaches isn’t well understood, so we group them by clinical pattern. The most common primary headache disorders are tension-type headache, migraine, and cluster headache.

By the way, if you are interested in the updated management of migraines, check the corresponding episode on this channel. The link to it is in the episode description.

Secondary headaches are due to underlying disorders including medication overuse headache, giant cell arteritis, raised intracranial pressure, and infection.

Headaches are very common and there’s often concern about possible underlying causes from both patients and healthcare professionals.

So, firstly, let’s look at when we need to consider further investigations or referral.

The NICE cancer guideline says that we should suspect a brain or a central nervous system malignancy in

·      adults if there is progressive, sub‑acute loss of central neurological function. We will refer them urgently for direct access, MRI scan of the brain to be done within 2 weeks. Alternatively, we can refer for a CT scan if MRI is contraindicated

·      In children and young people with newly abnormal central neurological function, we will arrange instead a very urgent specialist referral, that is, an appointment within 48 hours. 

There are some headache features that should also instigate further investigations or referral. The list is long and it includes symptoms such as:

• worsening headache with fever
• sudden‑onset headache reaching maximum intensity within 5 minutes
• new‑onset neurological or cognitive dysfunction
• head trauma within the past 3 months
• headache triggered by cough, sneeze or exercise or an
• orthostatic headache, that is, a headache that changes with posture

Additionally, we will consider further investigations or referral for people who present with new‑onset headache and:

• compromised immunity,
• a history of malignancy or
• vomiting without other obvious cause.

Once secondary causes of headaches have been excluded, then we’ll know that we are dealing with a primary headache. But, how do we differentiate cluster headache from other primary headaches such as migraine or tension-type headache?

Well, we will diagnose it according to the headache clinical features. So, let’s have a look at these features, and compare them with what we would expect in migraine and tension-type headache.

Let’s look at the pain location first. In cluster headache the pain location is unilateral, usually around the eye, above the eye and along the side of the head or face. In migraine it can be unilateral or bilateral and in tension-type headache it is usually bilateral.

The pain quality in cluster headache is variable. It can be sharp, boring, burning, throbbing or tightening. In migraine the pain is usually pulsating, although in young people it can also be throbbing or banging and in tension-type headache it is pressing or tightening and generally non‑pulsating.

The pain intensity in cluster headache is severe or very severe whereas in migraine it is moderate or severe and in tension-type headache it is mild or moderate.

When it comes to the effect on activities, there is restlessness or agitation in cluster headache. In migraine it is aggravated by, or causes avoidance of, routine daily activities whereas tension type headache is not normally aggravated by routine activities.

And finally, the duration of cluster headache is usually 15 minutes to 3 hours whereas in migraine it is usually 4 to 72 hours in adults, but sometimes shorter, from about 1 hour in young people. In tension-type headache it is usually anything from 30 minutes to continuous.

Cluster headache also usually presents with associated symptoms and we can consider them to help with the diagnosis.

For example, in cluster headache, on the same side as the headache we can find:

• a red or watery eye
• a swollen and or drooping eyelid
• a constricted pupil
• nasal congestion or a runny nose
• and forehead and facial sweating

On the other hand, common associated symptoms in migraine are unusual sensitivity to light or sound as well as nausea and vomiting. Additional, migraine can also have symptoms of aura, which can occur with or without headache.

Typical aura symptoms include speech disturbance, visual symptoms such as flickering lights, spots or lines and partial loss of vision; and also, sensory symptoms such as numbness or pins and needles.

 Generally, aura symptoms:

• are fully reversible
• develop over at least 5 minutes
• and last 5 to 60 minutes

However, we need to remember that tension type headache usually does not have any other associated symptoms.

If we look at the frequency of the headache, we can classify cluster headache in either episodic or chronic.

Episodic cluster headache has a frequency from once every other day to 8 times a day with a pain-free period of more than 1 month and

Chronic cluster headache is the same, that is, from once every other day to 8 times a day but with a continuous pain-free period of less than 1 month in a 12-month period.

And let’s remember that both migraine and tension-type headache can also be episodic when it happens fewer than 15 days per month or chronic when it is 15 or more days per month for more than 3 months.

Let’s now look at the management of cluster headache

And first of all, for people with a first bout of cluster headache we should consider neuroimaging, discussing with or referring to a specialist if necessary.

As the actual treatment for acute cluster headache, we will offer oxygen and/or a subcutaneous or nasal triptan. Currently, nasal triptans are unlicensed for this and the subcutaneous route is also unlicensed in under 18s.

When using oxygen for the acute treatment of cluster headache:

• we will use 100% oxygen at a flow rate of at least 12 litres per minute with a non‑rebreathing mask and a reservoir bag and
• we will arrange provision of home and ambulatory oxygen. 

When using a subcutaneous or nasal triptan, we will prescribe a sufficient number of doses, bearing in mind that the attacks may be multiple and frequent, so the quantity needed may also be significant.

We will not offer paracetamol, anti-inflammatory painkillers, opioids, ergots or oral triptans for the acute treatment of cluster headache.

What is the position in respect of prophylactic treatment for cluster headache?

NICE does not actually specify exactly when prophylactic treatment should be initiated. But in general, we should consider prophylaxis if:

• The patient has chronic cluster headache
• If attacks are frequent, severe, or disabling
• If there’s a need to reduce acute medication use
• And sometimes in episodic cluster headache, we can initiate prophylaxis early in a cluster period, ideally at the onset of symptoms, because, even if the bout is expected to last only a few weeks, prophylaxis can reduce frequency, severity, and duration of the attacks.

NICE recommends verapamil as the only option for prophylactic treatment during a bout of cluster headache. This is at the moment an off-label use of verapamil and, if we are unfamiliar with its use for cluster headache, we should seek specialist advice, including advice on ECG monitoring. The BNF actually says that it should be initiated under specialist supervision.

For cluster headache that does not respond to verapamil or during pregnancy, we should refer to a specialist

So that is it, a review of the assessment and management of cluster headache.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.