1. 16th September 2009 Lalitha Vaithianathar Cons. Neurologist, RDH
GP Trainees-Headache
16th September 2009
Lalitha Vaithianathar
Cons. Neurologist, RDH

2. Headache History Taking Headache Cases Clinical f’s and Mx of:
- Migraine
- Tension type h/a
- Medication overuse h/a
- Trigeminal Autonomic Cephalgias

3. Common causes of Headache
Primary h/a (%)
Migraine 16
Tension type 69
Cluster 0.1
Idiopathic stabbing 2
Exertional 1
Secondary h/a (%)
Systemic infection 63
Head injury 4
SAH <1
Vascular disorders 1
Brain tumour 0.1
(%) = prevalence

4. Sudden onset Headache PRIMARY SECONDARY Migraine
Benign exertional/coital. h/a
Cluster h/a
SECONDARY
SAH
Cerebral venous sinus thrombosis
Arterial dissection
Meningoencephalitis
Pituitary apoplexy
Acute hydrocephalus
Acute hypertension
Spontaneous intracranial hypotension

5. History taking in h/a

6. History taking in h/a Age of onset
1° h/a usually begins early in life (before age 30-40), de novo h/a after age 50 more likely 2°
Current symptomatic presentation-de novo or new h/a in known h/a sufferer
Frequency and Duration
most 1° h/a’s are part defined by attack freq and duration

7. History taking in h/a Onset tempo
“thunderclap” vs acute onset (mins-hrs) vs subacute progressive (ds-wks)
Timing-nocturnal, waking
Site, quality and character of h/a
Triggers, aggravating and relieving f’s e.g. valsalva, postural change, time of day

8. History taking in h/a Assoc. symptoms
premonitory, focal, n, v, photo/phono/osmophobia, mechanosenitivity, autonomic sx’s, systemic sx’s, assoc. behaviour
Drug Hx
previous and present Rx’s (acute and preventative)
Analgesic intake
Family and comorbid medical hx

9. Migraine

10. Migraine Migraine Without Aura- common type (80-90%)
Migraine With Aura -classic type (10-20%)
Subtypes:
Vertebrobasilar
Hemiplegic

11. Migraine without aura 5 attacks 4h-72hrs
H/a character (at least 2 features)
-unilateral
-throbbing/pulsating
-mod/severe
-worse with physical activity
Assoc. symptoms (at least 1 feature)
Nausea and/or vomiting
Photophobia and phonophobia

12. Migraine with aura >1 attack Typical features migraine without aura
Plus at least 3 of the following:
Fully reversible focal br.stem or cortical dysfunction
visual d including positive f’s (e.g. flickering lights, spots or lines) and/or negative f’s (loss of vision-scotoma, hemianopia, tunnel vision)
Sensory d of face/arm including positive f’s (e.g. p+n) and/or negative f’s (e.g.numbness)
Speech d-dysphasia
- Aura develops over >4 mins, may change type during the attack
- Each aura < 60 mins
- Headache < 60 mins following aura

13. Chronic Migraine
Migraine without aura, 15 or more days/mth for > 6 mths
No overuse of acute medication
Fulfills criteria for migraine without aura (but not each attack)
In practice often entangled with overuse of analgesics and triptans and CTTH
Difficult to define in pure form

14. Migraine-trigger f’s Relief of stress (e.g. weekends, holidays)
Hormonal changes (menstrual, menopause)
Physical exertion (sport, sex, work)
Change of routine (missed meals, sleep)
Visual glare, vivid patterns
Weather and atmospheric pressure changes
Foods and alcoholic drinks

15. Migraine Treatment
BASH (British association for the study of headache) guidelines:
Rest, sleep if possible
Acute rescue Rx :
Trial each Rx for at least 3 attacks
Based on recognition of attacks of different types/ severity can use different steps on Rx ladder
Acute Rx not to be taken regularly i.e. >2 days wk, risk medication overuse headache

16. Migraine Treatment Acute rescue Rx : Step 1:
Aspirin ( mg) or ibuprofen ( mg) dissolvable prep, taken early in attack. Paracetamol alone-little evidence. Avoid Opiates
Aspirin or NSAIDs with prokinetic anti-emetic e.g. domperidone (Alt, Prochlorperazine 3mg buccal tablet). MigraMax or Paramax
Step 2:
Rectal analgesic ± anti-emetic e.g. diclofenac 100mg/ domperidone 30mg suppositories
Step 3:
Specific anti-migraine drugs e.g. Tryptans, Ergotamine

17. Migraine Treatment Acute rescue Rx :
-Triptans (N.B. expensive, inter and intra patient variation of response, incomplete delayed benefit, recurrence of migraine, 10% overuse)
At least Mod severity attacks
Not during aura phase or before onset of pain
CI: uncontrolled HPn, at risk of cardiac ischaemia
Sumatriptan, Zolmitryptan, Rizatriptan (rapid onset), *Almotriptan, Naratryptan (slower onset, ?less recurrence), Frovatryptan (longer action)
Ergotamine useful for repeated relapse, as long duration of action (NB misuse potential)
Unlicensed options-high dose O2, parenteral steroids (dexa 4mg), parenteral diclofenac or phenothiazines (chlorpromazine 25-50mg)

18. Migraine Treatment Prevention of migraine (4 attacks/mth)
1st Line Drug Rx’s
B-Blockers: atenolol mg bd; propranolol LA mg bd,
Amitryptiline (10-150mg) 1st line if migraine co-exists with Tension type h/a, other chronic pain conditions, disturbed sleep or depression
2nd Line Drug Rx’s
Topiramate 25mg od- 50mg bd
Na Valproate mg bd
3rd Line Drug Rx’s
Gabapentin 300mg od – 800mg tds
Methysergide 1-2mg tds
B-Blockers with Amitryptilline
Flunarizine
Limited/uncertain efficacy: Pizotifen, Verapamil
If effective, continue for 4-6 mths
Hormone related migraine-keep diary (oestrogen withdrawel triggers migraine in some women)

19. Tension type h/a

20. Tension type h/a “Featureless h/a” At least 2 of the following:
Mild or mod intensity
Bilateral pain
Pressing/tight quality
No aggravation by simple physical activity
No nausea /vomiting; may have photo or phonophobia (not both)
Episodic (Attacks last 30 mins –7 days) or Chronic (>15 d/mth, for > 6 mths)
stress-related or assoc with functional or structural cervical/cranial musculoskeletal abnormality

21. Tension type h/a Treatment
Exercise, physio, lifestyle changes, relaxation/cognitive therapy, yoga/meditation
Episodic TTH: NSAIDS, paracetamol, avoid codeine
Chronic TTH: Amitryptilline (75-150mg/d). Dothiepin. Cognitive therapies, TENS, acupuncture

22. Medication overuse h/a
Common complicating issue in chronic daily h/a (typically pts with migraine or TTH)
Use of an acute attack Rx > 2d/wk regularly, usually with dose escalation over time
Compound OTC analgesics with combinations of paracetamol or aspirin, caffeine or codeine phosphate, or both; Triptans;
Rx: medication withdrawel
try naproxen mg bd for 3/52 as one off (may break cycle)

23. Trigeminal autonomic cephalgias

24. Cluster h/a Prevalence 0.1% Male:female ratio approx 5:1
Usually primary h/a disorder, occasl post-traumatic, or rarely secondary to pituitary tumour or aneurysm
Occasl familial cases 4-7%
Majority heavy smokers
Onset typically age 20-30
Triggers: alcohol (within 1hr), nitroglycerine,
exercise, warm room

25. Cluster h/a
Severe unilateral orbital, supraorbital, temporal pain lasting 15 mins-3hrs (rapid onset and cessation), boring or stabbing in nature
Freq 1-8/d (circadian periodicity)
Assoc with 1 of:
Lacrimation
Conjunctival injection
Nasal congestion
Rhinorrhoea
Forehead/facial sweating
Ptosis
Meiosis
Eyelid oedema OR
Sense of restlessness or agitation during h/a
Nausea, vomiting and photophobia rare

26. Cluster h/a
Treatment
General measures e.g abstaining from alcohol during attacks
Abortive agents: Triptans (Sumatriptan s/c 6mg), Oxygen 100% 7-12l/min, intranasal lignocaine
Preventative:
Short term: Steroids (Pred 60mg, tapering course 2-3/52);
Long term: Verapamil, Topiramate, Methysergide, Lithium

27. Paroxysmal Hemicrania
V. rare, MRI advised as rel. high incidence symptomatic cases
Female:Male 2:1
Episodic and chronic forms
Attacks shorter, more freqt than CH (upto 40/d)
Duration 2-45 mins
May be triggered by head/neck movement
v. severe orbital, fronto-temporal pain, ipsilateral cranial autonomic f’s, 50% show restlessness as in CH
Response to Indomethacin diagnostic

28. Summary Good history can distinguish between headache types
Headache management requires a flexible and individualised approach