Migraine Duration (hours 3 days) Without aura in 2/3 rd -unilateral, pulsating, moderate/severe intensity, aggravated by exercise, nausea/vomiting. Photophonophobia With aura in 1/3 rd - spreading scintillating scotoma, unilateral paraesthesia, dysphasia
Migraine-drug intervention Step one- simple analgesic+/- antiemetic Eg aspirin mg +buccastem 3-6mgbd Step two – rectal analgesic +/- antiemetic Eg diclofenac suppositaries+domperidone suppositaries Step three – triptans-use at onset of pain, not aura. Some rebound of symptoms in 20-50% of patients within 48 hours.
Migraine prophylaxis Ineffective for medication overuse headaches Use for 4-6 months-taper off over 2-3 weeks. Agents: betablockers, TCAD, pizotifen, gabapentin, lisinopril Other agents-topiramate, sodium valproate, clonidine Non drug therapies
Tension headaches Chronic tension type headache:- -more than 15 days per month - often daily -often stress/lifestyle related
Tension 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
Medication overuse headaches Affects 1 in 50 adults Females:males 5:1 First noted with phenacetin/ergotamine More common with aspirin/ NSAIDs/paracetamol/codeine/DF118 Can take several weeks to resolve after medication withdrawl Key feature-pre-emptive use of analgesia
Medication overuse headaches-cont. Low doses daily carry larger risk than higher doses weekly Esp common if using simple analgesia more days than not per month Using triptans, codeine >10days per month Worse on awakening in the morning Worse after physical exertion
Medication withdrawl headache-treatment Stage one-abrupt withdrawl most effective-Sx will worsen in days 3-7. Stage 2-recovery from MOH Stage 3- review and assess the underlying primary headache disorder Stage 4- prevent relapse Failure to withdraw- naproxen 250mgtds/500mg bd, tcad.
References Mentor/GP notebook BASH (British Association for the Study of Headaches)-guidelines. Neurological Differential diagnoses. Batten, J. 2 nd edition.