21st Oxford Symposium on Headache

Linbury Building

Worcester College

Walton Street

Oxford

 

Elizabeth Huzzey

 

Osteopath with a special interest in Headache Disorders. W1 CENTRAL LONDON & BERKHAMSTED CLINICSElizabeth has over 35 year experience practising osteopathy, in both NHS and private sectors. She qualified with a Master of Headache Disorders from the University of Copenhagen in 2020, was project lead for EdACHe, is a published researcher and holds the following positions. Honorary Advisor for British Association of Study of Headaches (BASH). Registered with the General Osteopathic Council (GOsC). Director of Osteopaths for Progress in Headache and Migraine (OPHM-Ed).

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Safe, Maybe, Avoid? Physio/osteo/chiro for head pain

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A brief introduction to the recently published International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention (IFOMPT). Aimed to support manual therapists assess for cervical vascular pathologies, balance the risk v benefit of their treatments and ensure best care for the patient.

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Alexandre Mathy

 

Alexandre Mathy is a Consultant Neurologist andLead Clinician for the Community Headache Clinic at Oxford University Hospitals 

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A 41 year old gentleman with severe headaches who refused medications

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Sometimes the patient knows better than the doctor. This is such a case.

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Gabriele Berman

 

Gabriele Berman, Consultant Neuro-Ophthalmologist, University Hospitals Birmingham, UK.

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The weight of the mind - just another headache?

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26 year old woman with new onset headache and blurry vision. This presentation will provide a case-based approach to evaluating bilateral optic nerve swelling, focusing on history taking, clinical examination, differential diagnosis and key investigations. Learning outcome: 1) Systematic approach to differential diagnosis of bilateral optic nerve swelling secondary to raised intracranial pressure. 2) identify red flags requiring referral or further investigation.

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Brian Burns

 

Dr Burns is a consultant neurology in Sheffield with an interest in headache and does a couple of headache clinics per week. Dr Burns has an MD (res) from UCL/ION in headache supervised by Professor Goadsby. 

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Anti CGRP drugs - are they safe and effective?

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Anti CGRP monoclonal antibodies and GPANTS have been recommended by NICE technology appraisals and are now widely used. These drugs have been studied and published by meta analysis methods, the results of which will be presented for efficacy and adverse effects. The outcome of an FDA based post marketing study will also be mentioned and the role of post marketing date for safety purposes. The talk will include a couple of cases to highlight these aspects of the drugs.

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Alex Valori

 

Alex graduated 1976 from St Andrews & Manchester, pursued surgery, and Orthopaedics after Fellowship, but diverted to General Practice in 1984. Surprised by the prevalence of unresolved Head, Neck & Facial pain, he explored other possible avenues of pain management. Observation of several cases of neck related headache was supported by anatomical review of Suboccipital Vector influences on the spinal origins of the Occipital Nerve system and the Trigeminal Spinal Nuclei. He has been in the Cervicogenic Headache International Study Group, made a clinical classification of Subocciptal Vectors, and designed appropriate injection treatments to relieve pain and promote rehabilitation of the C0/1/2 segments. He has run the Migraine clinic in the Neurology Dept at the Norfolk & Norwich Hospital since 1990, which is effectively a ‘pain clinic’, where a wide spectrum of chronic headache phenotypes may be treated from a cervicogenic viewpoint.

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Cluster Headache remission prolongation from Suboccipital Vector Injection treatment

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PIFU - patient initiated follow-up appointments going back 12 years have been reviewed .
Patients access the next clinic when a Cluster bout starts. Suboccipital Vector Injection treatment is the normal procedure applied. Statistical analysis indicates significant progressive prolongation of remission time. This implies a significant cervical influence in the genesis of Cluster Headache

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Helena Bridge

 

Helena Bridge has worked as an osteopath in SW London since 1991, and gained a masters in Clinical Management of Pain and Headache Disorders from the University of Edinburgh in 2020. She leads the student headache clinics at both the European School of Osteopathy in Maidstone, and the British College of Osteopathic Medicine in London. She was also the course creation lead on the 3-year EdACHe Project, a profession-wide headache education research project culminating in the rollout of an evidence-based e-learning course for allied health professionals in the musculoskeletal field.

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Cervicogenic hemicrania?

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When a patient's suspected TAC diagnosis fell between two ICHD-3 stools, a headache neurologist suggested a trial of manual therapy prior to initiating medical treatment.

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Mark McWilliam

 

Mark McWilliam has been the principal osteopath at the Cathedral Road Clinic in Cardiff for the past 21 years. He is a founder member and director of Osteopaths for the Progress of Headaches & Migraine (OPHM-ED ltd). Mark won the Welsh Pain Society prize in 2011 for his study into Chronic migraines and TTH and their associations with the neck. 

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If you are up to your neck with chronic migraine don't forget to breathe

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Case of a 52 year old female with chronic migraine who was referred to my clinic by a neurologist for me to treat the neck dysfunction related to this patients chronic migraines. The case aims to highlight the need to consider a broader focus when treating headache related neck pain beyond the cervical spine. It highlights the role the autonomic nervous system plays in chronic pain and how our breathing mechanics can affect our neck. It also aims to show how by examining and treating respiratory dysfunction can help improve clinical outcomes in patients with neck related symptoms to their headaches.

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Christopher Blatchley

 

Chris started the London Migraine Clinic over 10 years ago. It's aim is to explore new understandings of migraine, and sometimes to challenge the existing orthodoxy. I have been working with Arnold Wilkins for over 7 years to explore Daith ear piercing for migraine. This work continues, and this has led to the development of this Migraine Diary. Non-stick frying pans came from the flights to the moon! 

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Migraine Diaries - A new approach 

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Creating a Migraine Diary is difficult! The responses are essentially subjective. When is a headache a migraine? How do we measure severity? What are we really trying to measure? How does one get patients to fill them in? How long can they be? How frequent? Can we try to quantify purely subjective questions? Over the last 2 years I have been developing a weekly online questionnaire that takes 1 minute to fill in. It is aimed at measuring change over time, and has notes that can be added by both clinician and patient, and we are developing analytical tools to visualise trends. It is proving to be very useful, and patients like it!

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Michael Gross

 

Michael attended Sidney Sussex College, Cambridge before clinical training at The London Hospital. He had resident posts at The London Hospital, The London Chest, Hammersmith, Royal Free, The National, Queen Square and St Mary’s. He was appointed Consultant Neurologist and then Chairman of Neurosciences at The Royal Surrey County Hospital in 1990. He was the founder and Clinical Director of the RES Neurology Research unit which did extensive work in the fields of headache, epilepsy and fatigue states. In 1978 he and Ray Brettle first described the successful use of plasma exchange in the Guillain-Barre syndrome. Michael extended this work into his MD – “The Therapeutic Modification of Inflammatory Polyneuropathy” He was shortlisted “UK Hospital Doctor of the Year” in both 1998 and 1999. He left the NHS in 2001 concentrating on fulltime private clinical and medicolegal practise. Michael has joint accreditation in clinical neurology and neurophysiology. He belongs to a Central London Forensic Neurosciences Research Group meeting five times each year over the last 20 years. In 2012 he and his wife Karen, a career nurse, opened a 6000 sq ft. not for profit, outpatient Rehabilitation and Therapies Centre in Harrow, “The Body Factory” (www.bodyfactory.org.uk). When not in court he prefers to be on court, and enjoys 6 grandchildren, travel and photography.

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Finding the balance in migraine 

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My interest in balance disorders was enhanced when seeing identical twins at East Surrey outpatients around 1991. I will give brief details during the presentation. I suppose the absence of training mighty be a reason why so many people particularly in my medlegal practice are diagnosed so late with a balance disorder. With increasingly sophisticated vestibular function tests available there should be no reason why these long suffering people should not be diagnosed fully and treated appropriately. Three people are presented from a vast potential caseload illustrating the above. A brief account of some of the tests will be discussed. The philosophy of treatment is available as a supplementary information sheet.

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Tharuka Herath

 

Dr. H.M.M.T.B. Herath is a Locum Consultant Neurologist at Kettering General Hospital

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Predicting likelihood of idiopathic intracranial hypertension from imaging: A retrospective audit 

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Objectives - This retrospective study was carried out with the aim of identifying if MRI features in patients suspected of Idiopathic intracranial hypertension (IIH) are statistically significantly associated with the diagnosis.
Methods - MRI images of all patients diagnosed with IIH according to modified Dandy criteria and an age and gender matched group of patients who had a diagnosis of migraine were re-reviewed by a neuroradiologist who was blinded to the final diagnosis and clinical history.
Results - When each of the MRI features were considered separately (univariate analysis), seven features were statistically significantly associated with IIH (p<0.05). However, after adjusting for multiple comparisons and excluding collinearity, only 2 features were associated with a diagnosis of IIH (Bonferroni adjusted p value < 0.005). However, none of these features were independently associated with IIH when combined in a logistic regression. Thus, should not be used singly.
Conclusion - We agree that patients who are reported by radiologists as likely IIH needs further evaluation. While no individual feature could predict occurrence of IIH, a combination of features had a good sensitivity, specificity, positive and negative likelihood ratios. The imaging features identified in this study as being associated with IIH may be potentially useful to train an artificial intelligence-based algorithm to predict the likelihood of IIH from MRI, which in turn may be independent of the experience of the interpreter

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Danny Orchard

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Danny is an osteopath and senior lecturer at the University College of Osteopathy and writes the pain curriculum, having completed a MSc in Pain Science at Kings College, London, in 2012. He is also the Founder-CEO of the Centre for Osteopathic Research and Excellence (CORE), an East-London-based charity that helps chronic pain sufferers find relief using psychologically-informed manual therapy. Danny has recently been awarded an NIHR grant to study the possible role of osteopathy alongside psychotherapy for chronic pain patients with PTSD. When he’s not treating patients or teaching Danny is a keen mountaineer and can be found shimmying up a dank gully in North Wales. 

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Using Corticolimbic Pain Thresholds as a Model for Pain Management  

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In 2015, Baliki & Apkarian wrote a seminal paper in the journal Neuron where they first coined the term ‘corticolimbic threshold’ as a way of expressing the moment at which subconscious activity of nociceptive passes into conscious awareness to become ‘pain’. Since then, we have been using a variation of this model at the University College of Osteopathy to give patients a better understanding of how nociception and biomechanical load are important aspects in the presentation of pain but that they are only one dimension of this experience. The other critical dimensions to consider, the cognitive and emotional dimensions (often unhelpfully reduced simply to ‘psychosocial factors’) are often disregarded due to the sense that these are ‘psychological and we’re not psychologists’, or as manual therapists we should be fixing the ‘issues in the tissues’ etc. By using the corticolimbic threshold model we are better able to appreciate the fact that nociception on its own is neither sufficient or necessary to produce pain. And, furthermore, that the thoughts, beliefs and focus of the patient play a crucial role in the reduction or strengthening of the corticolimbic threshold and, therefore, determining whether the patient feels pain or not, often irrespective of the degree of tissue damage present. This model of corticolimbic thresholds can easily be translated to any pain patient, including chronic headache sufferers, to allow the patient to fully understand the role the nervous system and brain, and their thoughts and beliefs, play without reducing it to a cartesian mind-body split suggesting ‘it’s all in their head’.

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Jitka Vanderpol

 

Dr Jitka Vanderpol has been a Consultant Neurologist in United Kingdom since 2005. She graduated from the First Medical Faculty of Charles University in Prague, in 1998, and was nominated to become a Fellow of the Royal College of Physicians in London in 2012. She completed her MBA (exec.) with merit at Durham University Business School, UK, in 2014. Her main expertise is in the field of neurology, headache and migraine management. Dr Vanderpol is an innovative clinician and researcher. She was awarded First Place in the Innovative Technology or Device category at the Bright Ideas in Health Awards 2015. She is an Honorary Clinical Lecturer at University of Central Lancashire, a faculty member and speaker at Headache Academy in Royal College in London and UK Neurology Academy, former president of Anglo Dutch Migraine Association. She is a nationally recognised headache expert.

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Efficacy of greater occipital nerve block treatment for migraine and potential impact of patient positioning during procedure: Results of randomised controlled trial.

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Purpose: Assess the efficacy, and potential impact of patient positioning for 10 minutes immediately post-
procedure, of greater occipital nerve (GON) block for treatment of migraine. Methods: Prospective multicentre non-blinded randomised controlled trial, randomisation and treatment of 60 neurology clinic patients with poorly controlled migraine. Outcomes measured with Headache Impact Test-6 (HIT-6), modified MIgraine Disability Assessment Scale (M-MIDAS), and RELIEF scores. Results: Patient positioning did not lead to significant difference in RELIEF score (34% vs 11%, p-value 0.10, Chi-squared test) at day 90. When considered in a multiple regression analysis, the sitting position outperformed supine position significantly (p-value 0.04). However, no significant difference in HIT-6 score between the supine (n =27) and sitting position groups (n =33) was detected at baseline (p-value 0.76), day 30 (p-value 0.69) or day 90 (p-value 0.54, Mann-Whitney U-test). The HIT-6 score significantly improved post-GON block, from median 67 (baseline pre-GON) to 59 (day 30) and 62 (day 90) for the supine group and a score of 66, 61–62 for the sitting group (all p-value ≤0.001, intra-group comparison using Wilcoxon test); M-MIDAS achieved similar outcomes. Overall, a significant minimal clinically important improvement was obtained with GON block, and the GON injections were deemed very tolerable by patients (median score of 2 on 10 cm pain scale). Conclusion: Regardless of patient positioning, GON block is an effective and near-painless procedure for migraine symptom control. Unlike earlier published observational study data, this trial concludes that a sitting patient position immediately post-GON is preferred.

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Salika Karunanayaka​

 

I am currently practicing neurology as a trust grade registrar at Kettering general hospital. I hold a degree of medicine and MD in medicine from Sri Lanka. I am interested in in general neurology and headache disorders

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A 54-year-old male presented with 8-weeks history of right-sided headache

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A 54-year-old male presented with 8-weeks history of right-sided headache. Initially, the headaches were episodic, described as severe, sharp, and stabbing, involving the right periorbital and temporal regions. These episodes were of variable duration lasting from 60 to 120 minutes occurring 3 to 5 times per day. The headache was associated with autonomic symptoms, including redness, tearing, and ptosis of the right eyelid, which started before the headache and were reversible after the headache. There was no aura, photophobia, phonophobia, nausea, or dizziness. Features of increased intracranial pressure were absent. Three weeks later, the headache became continuous, fluctuating in severity, with superimposed attacks of more severe sharp, stabbing pain lasting 1–2 hours on a background of continuous throbbing pain in the same area on right side. Tearing and redness were intermittent with severe headache episodes, and the eyelid drooping became persistent.
On examination, there was right-sided miosis and partial ptosis (Figure 1) without ophthalmoplegia, which persisted. We did not perform the pharmacological test for Horner’s syndrome. Intermittent redness of the eyes was also noted (Figure 1). Fundoscopy was normal. Cranial nerve examination was otherwise unremarkable, and there was no sensory loss in the trigeminal nerve distribution. No sweating abnormalities were observed, and an iodine starch test was not performed. Imaging included an MRI of the brain, which excluded structural lesions in the hypothalamus, pituitary gland, superior orbital fissure, cavernous sinus, and brainstem. A CT angiogram of the brain ruled out intracranial aneurysms and cerebral venous thrombosis (CVT). Further CT scans of the neck and thorax showed no structural abnormalities affecting the cervical sympathetic trunk or ganglion. Blood tests, including CRP, ESR, and ACE levels, were normal. Temporal artery biopsy showed no abnormality. The patient’s headaches responded to subcutaneous sumatriptan 6 mg during acute episodes. There was no response to 100% oxygen. Indomethacin 25 mg three times daily was initiated, resulting in about 10% improvement after one week. The dose was increased to 50 mg three times daily, achieving 20% response, and further escalated to 75 mg three times daily. Headache resolved by week 4 with indomethacin 75 mg tds, except for occasional dull aches on the right side. Despite headache relief with indomethacin, the miosis and partial ptosis persisted at 3 months’ follow up. At 5 months follow up ptosis improved but miosis persisted. Discussion: Trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterized by headache with autonomic symptoms. Typically, these autonomic symptoms resolve with the cessation of headache episodes. Our patient did not appear to fit the criteria for any of the known primary headache disorders with associated autonomic phenomena, including cluster headache, short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT syndrome), migraine, chronic paroxysmal hemicrania (CPH), or hemicrania continua (HC). He had some features of HC, but the most interesting clinical sign was the persistent autonomic symptoms despite the resolution of headache. This presentation is consistent with long-lasting autonomic symptoms with hemicrania (LASH) syndrome, a rare TAC variant. LASH is defined by persistent autonomic features, such as ptosis and miosis, associated with hemicrania. In LASH, autonomic symptoms start before the headache and outlast the head pain [1,2,3]. It may be classified as primary or secondary. Secondary causes have been linked to pituitary tumours, trauma, or structural lesions[1]. However, this patient’s imaging excluded secondary causes. Our patient’s headache had a good response to indomethacin even though the response was delayed for several weeks. In some cases of LASH, autonomic symptoms also responded to indomethacin [1,2], but in our case they persisted. This may be a new, distinct indomethacin-responsive headache syndrome in the spectrum of LASH.LASH syndrome may be rare, but more reported cases are entering literature [2] making clinicians more aware of LASH. Key Point: Primary LASH syndrome should be considered in patients with trigeminal autonomic cephalalgia (TAC) presenting with persistent autonomic symptoms even after the headaches respond to indomethacin. Structural causes should be excluded through imaging.

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Stephanie Rodley

 

I am a Chartered Physiotherapist, HCPC, MMACP.I currently work in private practice in Northampton and use manual therapy and exercise based treatments. My particular area of interest is neck related/ cervicogenic headache, as well as the usual musculoskeletal conditions. 

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Cervicogenic/Neck Related headache, combined with a history of migraine.

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One patient’s story and a physiotherapist’s perspective.

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Paul Ballinger

 

I have been a GP in Cannock  for almost 30 years and have run a  headache clinic for the past 20 years taking referrals from 3 localities .A lot of my headache work has a large emphasis on injection therapy especially nerve blocks. I also do a lot of orthopaedic injection work and have an interest in diabetes in general practice.

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Winter Headaches

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I am presenting a case  of a patient who presents with recurrent episodes of short lived headaches which only occur seasonally during the winter months.I saw this patient recently for the first time and am hoping for some help in making a diagnosis

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Anish Bhara

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Anish Bahra is a consultant neurologist with a specialist interest in headache. Dr Bahra has been part of the general neurology team at Whipps Cross Hospital since 2003 and ran a tertiary headache service at the National Hospital Neurology and Neurosurgery (NHNN) until 2022. She has now moved her specialist service to the multidisciplinary Facial Pain service based at the Pain Management Centre, NHNN @ Cleveland Street and headache service to Oxford University Hospital. Dr Bahra’s research was in cluster headache at the Institute of Neurology, UCL. She is a Life Member and currently a trustee of OUCH, the Organisation for the Study of Headache. She is a council member of BASH, and part of the BASH Guideline group which published the updated national headache guidelines in 2019. She is on the editorial board of the ACNR (Advances in Clinical Neurosciences and Rehabilitation) and Brain Research UK Scientific Advisory Board.

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64 year old referred for management of migraines, with background of IIH and ongoing investigation for a neuromuscular disorder

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Khadija Jarari

 

Dr Khadija Jafari is a graduate of the University of Birmingham, currently a senior house officer in Acute Medicine at Prince Charles Hospital. She is working closely with Dr Hassan to develop community pathways for headaches and expanding her interests in rare illnesses and disease.

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Spontaneous Intracranial Hypotension at the front door

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Spontaneous Intracranial Hypotension (SIH) is a rare condition characterized by a low cerebrospinal fluid (CSF) volume, often resulting from CSF leaks at the level of the spine. It typically presents with a variable clinical profile, including orthostatic headaches. Although it can affect individuals of all ages, it is more commonly seen in middle-aged adults. Due to the variability in clinical presentation and limited awareness of this condition, there is often a delay in diagnosis which itself is challenging and requires a high index of suspicion. This presentation will discuss the clinical features, diagnostic approaches, and current treatment options for SIH. There will be local cases for discussion including their imaging findings.

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Freya Crispin

 

Dr Freya Crispin is a Senior House Officer in Prince Charles Hospital, currently working in the Acute Medicine Team. She intercalated in Neuropsychology during her medical degree and currently assists Dr Hassan in his headache clinic. She has an interest in headaches and migraines.

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Skin manifestations of migraine

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Skin manifestations are not currently a recognised part of the ICHD-3 algorithmic system to classify and diagnose migraines. However, in this presentation we will explore several cases, from our practice and the literature, where there have been reported changes to the skin related to patient’s migraine episodes. We aim to find out if there is a correlation in these changes with the phases of migraine and the potential pathophysiology behind them.

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<< This educational meeting is supported by AbbVie, Lundbeck, Organon, and Pfizer, These companies were not involved in the choice of speakers or preparation of the meeting content. >>

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