1. Headache Guideline Cumbria
Cumbria Partnership NHS FT- Neurology Department
Headache Clinic Penrith
Primary headache disorders
Primary headache disorders are not associated with underlying pathology. Most common are migraine, tension headache and cluster headache.
Secondary headache disorder
Headache attributed to underlying pathological condition, includes infectious, vascular, neoplastic and drug induced origin.
Tension Headache
Migraine
CHARACTERISTICS:
episodic
unilateral
pulsating
moderate to severe in intensity
associated with nausea or vomiting and/or sensitivity to light
aura (in 15–33% of patients)
exacerbation by physical activity
sensitivity to light between attacks
Often positive family history of migraine
Normal neurology assessment
no red flags
TREATMENT:
Lifestyle advice
Acute treatment
CHARACTERISTICS:
Bilateral
pressing or tight band like
no nausea
not aggravated by physical activity
may be pericranial tenderness, sensitivity to light or noise.
TREATMENT:
Lifestyle advice
Acute treatment
Aspirin, Paracetamol and NSAID are recommended for acute
treatment in patients with tension-type headache.
3. Prophylaxis
Tricyclic antidepressants (particularly Amitriptyline 25 – 75 mg)
recommended as the agents of choice in a patient with chronic
tension-type headache.
4. Non pharmacological therapy
Complimentary therapies
Stress management
Alternative medicine
See BNF for further advice about the doses
Opioid analgesics should not be routinely used for the treatment of patients with acute migraine due to the potential for development of medication overuse headache!
Aspirin 900 mg or NSAID Ibuprofen 400 mg or Paracetamol 1,000 mg is recommended for mild to moderate migraine.
Oral triptans in patients with all severities of migraine if simple analgesics did not help previously. Should be taken at the onset of the headache.
A combination of Sumatriptan mg and Naproxen mg may be helpful in acute migraine, particularly in prolonged attacks which are associated with recurrence.
Oral and rectal anti-emetics can be used in patients with acute migraine attacks to reduce symptoms of nausea and vomiting
Suppository, nasal spray or injections are preferred route of treatment administration for the vomiting patient.
3. Prophylaxis
For the patient with more than two severe attacks of migraine monthly
First line choices: Propranolol, Pizotifen, Amitriptiline
Second line choice: Topiramate 25 mg – 50 mg at night.
See BNF for further advice about the doses
Referral for BOTOX treatment for Chronic migraine if 15 or more
migraine days monthly and the above treatment failed.
Investigation
Neuroimaging is not indicated in patients with a clear history of migraine, without red flag features for potential secondary headache, and a normal neurological examination.
Cluster headache
Cervicogenic headache
CHARACTERISTICS:
Cluster headache is trigeminal autonomic cephalalgia, characterised by attacks of severe unilateral usually sharp short lasting pain in a trigeminal distribution associated with ipsilateral cranial trigeminal autonomic features (tearing from eye, drooping eye lid, redness of face blocked nostril). Typically restlessness during the attack.
CHARACTERISTICS:
Usually occipital radiating to the frontal regions
Dull or tight band like sometimes sharp shooting
Mild to moderate in intensity
Worse with neck movements
No nausea
Not aggravated by physical activity
1. Acute treatment
Aspirin, Paracetamol and NSAID are recommended
2. Prophylaxis
Amitriptyline mg per day, are recommended as the agents of choice where prophylactic treatment is being considered in a patient with chronic Cervicogenic headache.
3. Non pharmacological therapy
Physiotherapy, complimentary therapies, Alternative medicine.
See BNF for further advice about the doses
Refer patient with neuralgia or radicular irritation for assessment to the Headache Clinic
1. Acute treatment
Subcutaneous injection of 6 mg Sumatriptan is recommended as the first choice treatment
Nasal sumatriptan or Zolmitriptan in patients who cannot tolerate subcutaneous sumatriptan.
Oxygen 10 – 15 l/min, nasal mask in sitting position (see BASH guidelines)
2. Prophylaxis
Verapamil mg is recommended for the prophylaxis
Topiramate mg bd
See BNF for further advice about the doses
Refer each patient with suspected Cluster Headache to the Headache Clinic
Analgesia overuse headache
Secondary headache
Red flags which should prompt referral for further investigation:
New onset or change in headache Thunderclap: rapid time to peak headache intensity (seconds to 5 mins)
Focal neurological symptoms
Non-focal neurological symptoms (eg. cognitive disturbance)
change in headache frequency, characteristics or associated symptoms
Abnormal neurological examination
Headache that changes with posture
Headache on awakening
Headache precipitated by physical exertion or Valsalva manoeuvre (eg coughing, laughing, straining)
Jaw claudication or visual disturbance
Meningeal signs eg. neck stiffness, fever,
New onset headache in a patient with a history of HIV infection
CHARACTERISTICS:
Headache which is present for 15 days or more per month and which has developed or worsened while taking regular symptomatic analgesia medication.
Medication overuse headache must be excluded in all patients with chronic daily headache
Opioid-containing medications use or overusing triptans are at most risk.
Treatment:
Opioid-containing analgesics should be considered for gradual withdrawal.
If frequent headache persists after symptomatic medications have been withdrawn, prophylactic agents should be considered (Amitriptyline mg per day.
! Abrupt withdrawal from medication can initially results in worsening of headache.
Psychiatric co morbidity and dependence behaviour should be considered and treated.
Referral to a psychiatrist or a clinical psychologist should be considered.
Further info:
Penrith Headache Clinic
New onset headache in a patient with a history of cancer.
Patients who present with headache and red flag features of potential secondary headache should be referred to specialist for further assessment and investigation, CT brain scan, in some cases MRI.
Thunderclap Headache
A high-intensity headache of rapid onset reaching maximum intensity in less than a minute in most; subarachnoid haemorrhage is the commonest, other conditions can also present (intracerebral haemorrhage, cerebral venous sinus thrombosis, arterial dissection, pituitary apoplexy).
Patients should be referred immediately to hospital for same day specialist assessment and investigation CT brain scan performed preferably within 12 hours of onset.
If normal CT, patient should have a lumbar puncture, oxyhaemoglobin and bilirubin should be included in CSF analysis, ASAP after 12 hours.
In delayed presentations, lumbar puncture can be performed up to two weeks from onset of symptoms.
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