1. Migraine and other headaches
Dr David Kernick
Exeter Headache clinic

2. Outline Where does headache come from? Epidemiology Classification
Management

3. HEADACHE – pain from cranium that can be reffered
to or from the neck and face

4. Extra cranial origin

5. Where does the pain come from? Extra - cranial
Arteritis
Neuralgia
Muscle tension
Facial structures

6. Intra cranial pain

7. CSF – 20 mls/hr, 150 mls capacity

8. Where does the pain come from? Intra – cranial (dural pain fibres)
Tension – raised intracranial pressure
Compression – tumour
Inflammation - migraine,meningitis,blood

9. From neck

10. Migraineur on metopralol. Uses salbutamol inh 5 times a week.

12. Respiratory effect of beta-blockers in people
with asthma and cardiovascular disease:
population-based nested case control study
Daniel R. 2017

13. 35,502 with active asthma and CVD
14.1% and 1.2% were prescribed cardioselective and non-selective beta-blockers
Results
Beta-blocker use was not associated with a significantly increased risk of moderate or severe asthma exacerbations.
Conclusion
Cardioselective beta-blockers in asthma and CVD were not associated with a significantly increased risk of moderate or severe asthma exacerbations and potentially could be used more widely when strongly indicated.

14. Outline Where does headache come from? Epidemiology Classification
Management

15. Epidemiology Prevalence Incidence Impact – QoL, Economic
Health seeking behaviour

16. Headache annual prevalence
Population:
Tension type 70%
Migraine 12%,
Cluster 0.1%

18. Annual Migraine incidence

19. Epidemiology Prevalence Incidence Impact – QoL, Economic
Health seeking behaviour

20. National Challenge Reference
Approximately 9 million people live with migraine in the UK
Migraine: the seventh disabler (Steiner et al 2013)
Migraine is the second leading cause of years lived with disability
Global Burden of Disease (The Lancet 2016)
25 million days lost from work or school each year in England because of migraine alone
The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. (Steiner et al 2003) 20

21. Headache impact
20% adult population – headache impacts on their quality of life Kernick 2001

22. Impact upon children
Kernick BJGP 2009
20% - 1 or more headaches each week, significant impact home or school

23. University new entrants Kernick 2002
1124 students
21% headache that impacted on life
13% > 15 days of the month
45% seen a GP
<5% prescribed medications for headache

24. Epidemiology Prevalence Incidence Impact – QoL, Economic
Health seeking behaviour

25. When people develop headache what do they think they have
When people develop headache what do they think they have? What do GPs think they have? What do they actually have?

26. When people come to see you what do they think they have?
Need glasses
Blood pressure
Brain tumour

27. What do GPs think when patients present with headache? (Kernick 2008)

28. What do patients have when they present to GP with headache
What do patients have when they present to GP with headache? Landmark Study
85% migraine
10% Tension type headache
5% secondary headache
<1% other types of headache

29. What happens? Less than 50% migraineurs will see GP
Less than 10% will receive Triptan Walling 2006
10% of those who would benefit from prevention receive it Rahimtoola 2005

30. What happens?
3% GP presentations are referred to secondary care (25% children)
(Loughey)
30% of neurology referrals are for headache (Hopkins)

31. What do patients have when they present to A and E with headache
What do patients have when they present to A and E with headache? Valade 2000
Migraine 55%
TTH 25%
Cluster %
Trauma %
Trig Neuralgia 1.6%
Sinusitis %
Vascular disorders 1.2%
Low Pressure 1.2%
Meningitis %
Tumour %
Other Misc < 5%

32. What is the unmet need in primary care?
Kernick Journal of Headache and Pain 2008
< 50 % adults, <10% children see GP

33. Why don’t people seek help?

34. Why don’t people seek help?
Can’t measure
Only a headache
Everyone gets them – natural
No one takes me seriously
Parents don’t want to reinforce illness behaviour - pattern their health seeking behaviour

35. How should we deliver headache services
Self management
GPs first line management
GPSI support
Tertiary headache centres

36. Outline Where does headache come from? Epidemiology Classification
Management

37. IHS Headache classification Primary Secondary
Traumatic
Vascular
Non-vascular (SOL)
Substance induced
Infection
Disturbed homoestasis
Facial structures
Migraine
Tension type
Autonomic cephalalgias (cluster)

38. Headache Pathway EXCLUDE A SECONDARY HEADACHE Do something now
Do something soon
DIAGNOSE A PRIMARY HEADACHE
Exclude medication overuse and manage the primary headache

39. Headache Pathway EXCLUDE A SECONDARY HEADACHE Do something now
Do something soon
DIAGNOSE A PRIMARY HEADACHE
Exclude medication overuse and manage the primary headache

40. 70 year old drug review Simvastatin Thyroxine Amlodipine Bendrofuazide
Developed dull L sided headache. Gets pain in his jaw on eating. Should he see the dentist?

41. Sub Arachnoid - thunderclap headache

43. Reversible vasoconstriction syndrome
Vasoconstrictor drugs, SSRIs, Cannabis

44. Thrombophilia

45. Meningitis

46. Malignant hypertension

47. Temporal arteritis Can be bilateral Systemically unwell
Tender artery with allodynia
CRP better than ESR
Problem with skip lesions

48. Headache Pathway EXCLUDE A SECONDARY HEADACHE Do something now
Do something soon
DIAGNOSE A PRIMARY HEADACHE
Exclude medication overuse and manage the primary headache

49. Exercise headache
1/3

50. Pressure – too high. Idiopathic intracranial hypertension
Non specific headache
Tinnitus
Visual field/acuity defect
Papilloedema

51. CSF – 20 mls/hr, 150 mls capacity

52. Pressure too low

53. Space occupying lesions Stretch, compression, blockage
Benign – cysts, A-V malformations
Malignant – primary secondary

56. Red Flags Abnormal neurological symptoms or signs
History of cancer elsewhere

57. Orange Flags Aggregated by Valsalva manoeuvre
Headache with significant change in character
Awakes from sleep
New headache over 50 years
Memory loss
Personality change

58. Headache Pathway EXCLUDE A SECONDARY HEADACHE Do something now
Do something soon
DIAGNOSE A PRIMARY HEADACHE
Exclude medication overuse and manage the primary headache

59. Drug review
1. Paracetamol, co codeine or Ibuprofen on 17 days of month
2. Sumatriptan 8 days of month
Is he likely to have MOH, from 1 or 2?
Which drug is most likely to cause a problem?

60. Medication overuse Headache
3% of population
Analgesics > 15 days of month
Triptans > 10 days of month

61. Medication overuse headache
Withdrawal of all analgesia
Increased frequency of headache,
associated with increased frequency of analgesia use.
Return of episodic
headache
Daily headache with spikes of more severe pain
Headache intensity
Migraine attacks
Management?
Frequent ‘daily’ headaches 35

62. Headache Pathway EXCLUDE A SECONDARY HEADACHE Do something now
Do something soon
DIAGNOSE A PRIMARY HEADACHE
Exclude medication overuse and manage the primary headache

63. Primary Headaches Migraine Tension Type Cluster Paroxysmal hemicrania
Hemicrania continua
SUNCT
Primary cough headache
NPDH ect

64. A 30 year old male Pain in L eye Lasts 30 minutes, 5 times a day
GP diagnosed migraine given oral sumatriptan 100mg and propanolol 160MR but not working?

66. Cluster - Autonomic Cephalopathy
High impact ++
Peri-orbital clusters 15mins - 3 hours
Cluster attacks and periods
Unilateral autonomic features
Acute or chronic

67. Cluster treatment Injectable Sumatriptan Nasal Zolmitriptan
Short term steroids
Oxygen 100%
Verapamil

68. Tension type headache
Cervico-genic (degenerative change, trigger spots)
Muscle tension
Mandibular
Anxiety-depression

69. Migraine – the default diagnosis

70. Migraine generator – gastric and cervical implications
Central and peripheral sensitisation
Activation trigeminal nerve
Peripheral inflammation
Cortical depolarisation and vasoconstriction
Classifying headache 2

71. Implications for gastric stasis and neck pain

72. Migraine: A Featureful Headache
Cady, p 206, C1 Par 2 L 1-12
Cady, p 206, C2 Par 2 L 1-4
Premonitory
Mood changes
Fatigue
Cognitive changes
Muscle pain
Food craving
Fully reversible
Neurological changes: Visual somatosensory
Aura
Dull headache
Nasal congestion
Muscle pain
Early Headache
Unilateral
Throbbing
Nausea
Photophobia
Phonophobia
Osmophobia
Advanced Headache
Fatigue
Cognitive changes
Muscle pain
Postdrome
Cady, p 206, C2 Par 3 L 4-6
Cady, p 207, C1 Par 1 L 1-11
Linde, p 71, C2 Par 1 L 4-9
Linde, p 74, C1 Par 3 L 1-15
Key point: Migraine is manifested clinically as a constellation of symptoms that evolve through the
various phases of a migraine attack; clinical experience indicates that symptoms typically associated
with each phase of an attack often recur during other phases of the attack, resulting in a continuum of
symptoms, rather than a succession of distinct phases.
CLINICAL PHASES OF MIGRAINE1
A migraine attack can take days to develop and resolve; headache is only 1 of several symptoms associated with migraine.1
Although the symptoms of migraine often overlap, the classic view is to separate an attack into phases.1
The Premonitory Phase1
Seventy percent of patients suffering from migraine with or without aura experience premonitory symptoms.1
Premonitory symptoms are often seen as predictors of the headache attack. 1
Mood alterations, muscle pain, food cravings, cognitive changes, fluid retention, and yawning are common premonitory symptoms.1
Eighty-three percent of subjects with premonitory symptoms could predict over 50% of their attacks.1
The Aura Phase 1
An aura involves focal, reversible neurologic symptoms that often precede the headache.1
Aura symptoms are believed to arise from an electrical disturbance called cortical spreading depression (CSD); it occurs in approximately was 15-32% of migraine attacks.1,2,3
Auras are not always followed by headache pain; such auras are called acephalgic migraine or migraine aura without headache.1
The Headache Phase1
The headache phase is subdivided according to headache pain intensity into an early phase and an advanced phase.1
Early headache: mild pain without the associated symptoms of migraine1
Advanced headache: moderate to severe pain with the associated symptoms of nausea, photophobia, phonophobia, or disability; used to confirm a migraine diagnosis1
Postdrome1
Phase of migraine-associated symptoms beyond the resolution of the headache; often entails significant disability that can last for 1 or 2 days.1
R1, p 206, C1,
Par 1, L 1-14
Preheadache
Mild
Moderate
Severe
Post headache
Time
R1, p 206, C1,
Par 2, L 1-12
and C2, Par 1,
L 1-9
Headache
R1, p 206, C2,
Par 2, L 1-13
R2, p5, para3, L1-2
R3, p222-3, last para-cont, L11-12
R1, p 206, C2,
Par 3, L 1-7
and p 207, C1,
Par 1 and Par 2
R1, p 207, C1,
Par 3, L 1-4 72
References:
Cady R, Schreiber C, Farmer K, Sheftell F. Primary headaches: a convergence hypothesis. Headache. 2002;42(3):204–216
Launer LJ, Terwindt GM, Ferrari MD. The prevalence and characteristics of migraine in a population-based cohort: the GEM study.
Neurology. 1999; 53(3): 537—542.
3. Rasmussen BK, Olesen J. Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia.1992;12(4): .

73. In practice Recurrent headache that bothers Nausea with headache
Light or sound bothers
Invariably a family history

74. Migraine co-morbidities
Anxiety
Depression
IBS
Asthma
Epilepsy

75. Migraine Acute treatment
Paracetamol, Aspirin, Prokinetic (Domperidone/metochlorpropramide).
Triptan
Not opiates

76. Triptans

77. Triptan Half Life

78. Severe nausea, often vomits
Sumatriptan 50mg only partially effective

79. Options Anti emetic Take early Change the dose
Change formulation (nasal, wafer, inj)
Change the Triptan (failure not a class effect)

80. Taking Sumatriptan 100mg Which cause you concern?
On COC pill
Age 69
Past history TIA
Started SSRI

82. Triptans – some practical points
Treat early
Formulation?
Failure not class effect
Not in CVD
SSRIs
Over 65 years

83. Migraine treatment Preventative
When to instigate?
How long for to assess an effect?
What rate dose increase?
How long on preventative medication?
What to use?

84. Preventative Medications in Migraine
Cupboard 1
Propranolol
Amitriptyline
Topiramate
Cupboard 2
Gabapentin / Pregabalin
Candesartan
Venlafaxine / Duloxetine
Flunarizine
(requires hospital prescription)
Sodium Valproate
(not in women of childbearing age)
Cupboard 3
Other anti-epileptics
Lisinopril
Pizotifen

85. Migraineur on verapamil, domperidone, Triptan
Migraineur on verapamil, domperidone, Triptan. Just started on Amitriptyline

87. Patient read in Daily Mail about new “breakthrough” drug
Patient read in Daily Mail about new “breakthrough” drug. How do you advise?

88. CGRP antagonists

89. Non – drug options

90. Triggers/lifestyle Triggers – yes
Lifestyle - yes (including hormones) Keep constant
Food allergy - no

91. Naturally occurring drugs
Magnesium – ?yes
Co Q10 – ?yes
Feverfew, butterbur, riboflavin – possibly

92. Needles – occipital nerve injection

93. BOTOX® for Chronic Migraine
Needles - Botox
BOTOX® for Chronic Migraine
UK licence for Chronic Migraine, NICE approved
≥15 days headache of which ≥8 days are migraine
Rejected by SMC (2011 and 2013)
Starting to be used in patients where most other treatments have failed
Mean change in frequency of headache days from baseline (days/28-day period) 52 48 44 40 36 32 28 24 16 12 8 4
Study week 20 56 -2 -4 -6 -8
-10
-12
-14
BOTOX® (n=688)
Placebo (n=696)
p=0.019
p=0.047
p=0.007
p=0.01
p=0.008
p<0.001
Double-blind phase:
BOTOX® vs. placebo
Open-label phase:
All patients on BOTOX®
p=0.011

94. Needles - accupuncture

95. Psychological approaches
Cognitive therapy, mindfulness

96. Electrics

98. Transcutaneous vagal nerve stimulation

99. Supra-orbital nerve stimulator

100. In summary
Lot of it out there
Significant impact
Needs unmet