10Migraine Duration (hours3 days) Without aura in 2/3rd -unilateral, pulsating, moderate/severe intensity, aggravated by exercise, nausea/vomiting. PhotophonophobiaWith aura in 1/3rd- spreading scintillating scotoma, unilateral paraesthesia, dysphasia
11Migraine-drug intervention Step one- simple analgesic+/- antiemeticEg aspirin mg +buccastem 3-6mgbdStep two – rectal analgesic +/- antiemeticEg diclofenac suppositaries+domperidone suppositariesStep three – triptans-use at onset of pain, not aura. Some rebound of symptoms in 20-50% of patients within 48 hours.
12Triptans Sumatriptan 50-100mg Zolmitriptan 2.5mg then rpt after 2 hours (not children)Rizatriptan 10mg (equiv sumatriptan 100mg)Almotritan 12.5mg-HIGH EFFICACY. COST EFFECTIVE
13Migraine prophylaxis Ineffective for medication overuse headaches Use for 4-6 months-taper off over 2-3 weeks.Agents: betablockers, TCAD, pizotifen, gabapentin, lisinoprilOther agents-topiramate, sodium valproate, clonidineNon drug therapies
15Tension headaches Chronic tension type headache:- -more than 15 days per month- often daily-often stress/lifestyle related
16Tension headaches Episodic tension-type headache- -may be unilateral but tend to be generalised- pressure/tightness- often spreads from neck-stress related or related to cervical/cranial musculoskeletal anomalies
18Medication overuse headaches Affects 1 in 50 adultsFemales:males 5:1First noted with phenacetin/ergotamineMore common with aspirin/ NSAIDs/paracetamol/codeine/DF118Can take several weeks to resolve after medication withdrawlKey feature-pre-emptive use of analgesia
19Medication overuse headaches-cont. Low doses daily carry larger risk than higher doses weeklyEsp common if using simple analgesia more days than not per monthUsing triptans, codeine >10days per monthWorse on awakening in the morningWorse after physical exertion
20Medication withdrawl headache-treatment Stage one-abrupt withdrawl most effective-Sx will worsen in days 3-7.Stage 2-recovery from MOHStage 3- review and assess the underlying primary headache disorderStage 4- prevent relapseFailure to withdraw- naproxen 250mgtds/500mg bd, tcad.
21References Mentor/GP notebook BASH (British Association for the Study of Headaches)-guidelines.Neurological Differential diagnoses. Batten, J. 2nd edition.