Headaches Jo Swallow ST1s May 2009

Roberta 44yrs, headache Roberta presents to your surgery on Friday afternoon. She says that she has had terrible migraines most days over the past 3 months. What important features do you need to elicit in the history What examination would you like to perform? ?Investigations ?management plan

Primary/Secondary Migraine Cluster Tension Medication induced ?secondary to intracranial lesion

Migraine periodic headaches with complete resolution between attacks Sequence may occur: Prodrome Aura Headache Resolution

Prodrome features mood changes coldness or warmth anorexia or increased appetite heightened sensitivity to light, sound and smell

Aura often consisting of bright specks of light hemianopia, expanding scotoma, constricted visual fields aura usually precedes the headache, but may accompany it and usually lasts 15-20 min fortification spectra, which are often 'C'-shaped objects may rotate, oscillate, or 'boil' simple flashes, specks, and shimmerings

Who painted this? Name?

Aura

Aura http://www.nytimes.com/slideshow/2008/02/28/opinion/20080222_MIGRAINE_SLIDESHOW_12.html

Aura 1 Headache follows certain changes that take place in the nerves to the major blood vessels in the head. The aura is due to changes that take place in the cortex, the outer layer of the brain.

Aura 2 In experiments with animals, the EEG shows a depression (lowering) of nerve cell activity below a spot on the cortex of the brain that has been stimulated. Surrounding the area of depressed activity is a zone in which nerve cells have become hyperactive. It's thought that a similar pattern of decreased and increased nerve cell activity occurs in the brain of a person with migraine, following the stimulus of a migraine "trigger."

Aura cause When the activity of nerve cells is depressed, there is impairment of function in the part of the body controlled by these cells. For example, there may be a loss of vision or of strength. Increased activity of brain nerve cells may result in flashing lights or tingling in the face and hand. In the experiments with animals, the depression of nerve cell activity slowly spreads beyond the initial spot of stimulation. This phenomenon is called spreading depression. It is preceded by a wave of increased nerve cell activity.

Aura cont… paraesthesiae are the second most common type of aura. Numbness usually starts in the hand, migrates up the arm, then involves the face, lips, and tongue. The leg is sometimes involved. Numbness may follow the paraesthesia. Sensory auras rarely occur alone, and usually follow visual auras speech disturbances are the third most common

Differentiating migraine and tension headache migraine is therefore a head pain head pain with associated features (contrasting with tension-type headache which is featureless head pain) migraine is often associated with onset after confrontation to particular triggers

Migraine vs. tension boring or squashing, bilateral head pain Pain throbbing, unilateral head pain worsening of pain with movement vs. nausea and vomiting, phonophobia or photophobia poss. boring or squashing, bilateral head pain No assoc features

Migraine triggers altered sleep patterns (too little or too much sleep may precipitate migraine) overexertion skipping meals changes in stress level - may be too much or too little relaxation excess of afferent stimuli e.g. bright lights changes in the weather may precipitate migraine attacks menstruation chemical trigger e.g. delayed headache after glyceryl trinitrate or

Gastric stasis soluble aspirin 600-900 mg stat in adults paracetamol 1 g - adult dosage non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 1.2-1.6 g daily in divided doses An anti-emetic such as metoclopramide or domperidone not only relieves nausea that accompanies may migraine attacks but also enhances the efficacy of simultaneously administered oral analgesics diclofenac suppositories 100mg for pain plus domperidone suppositories 30mg (if vomiting)

2nd line migraine treatment Sumatriptan is a 5-HT 1 receptor agonist used for the acute treatment of migraine and cluster headache. and as a nasal spray. Prophylaxis Atenolol/propranolol Amitryptilline Ramipril Gabapentin

Treatment of tension headache Lifestyle change Alternative therapies MEdication low doses are effective e.g. amitriptyline, initially 10 mg nocte rising if required to 50-100 mg daily Consider trial without if asymptomatic > 6months