1. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Headache Jane Smith, a 23 year old woman, presents to her GP complaining of headaches. What information would you need from her?

2. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Timing (how recent, frequency and temporal pattern, how long lasting, why consulting now?) Character (severity, quality, site and radiation, associated symptoms) Cause (triggers, exacerbating or relieving factors, family history) Response (what treatments tried and how, how disabling, what does patient do during attack) Health between attacks (persisting symptoms?) Past history of headaches Other medical problems and medication (prescription and over-the-counter (OTC)) Ideas, Concerns, Expectations

3. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Miss Smith is a trainee manager in a supermarket. She describes recurrent headaches over the past 6 months. The pains come on gradually but build up over a couple of hours and are often so bad that she has to go and lie down in a dark room. The pains are usually associated with nausea, but she has not noticed any other symptoms. She describes the headaches as ‘throbbing’ and localised above one eye (usually the left). She has tried taking Ibuprofen and Paracetamol, but they don’t seem to help very much and the pain can last all day before gradually disappearing. The headaches occur about two or three times a month, often on her days off, although she has missed work because of them. She has not noticed any particular triggers and they are not related to her periods. She has not previously suffered from headaches and has no relevant family history. She is asthmatic but has no other significant health problems and is well between attacks. Her only medication is the combined oral contraceptive pill (Microgynon) which she has used for 3 years and her asthma inhalers (Beclometasone and Salbutamol). She has read the patient information leaflet for Microgynon and wonders if this is causing her headaches. She would like to try changing to an alternative brand.

4. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE What is the diagnosis and which features of the history lead you to this conclusion?

5. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Migraine Severe episodic throbbing unilateral headaches Assoc. nausea and photophobia Disabling Gradual onset Duration hours Well between attacks Patient factors (age, general health, no ‘red flags’) NB migraine without aura is about twice as common as migraine with aura

6. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Is her contraceptive pill likely to be the cause of her migraine?

7. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Migraine is more common in women taking the contraceptive pill The association is not clear cut Since she has been on the pill for 2.5 years with no problems – the pill is unlikely in this case to be causative Options need to be discussed with the patient: –She could try an alternative method of contraception –She could experiment with an alternative pill (lower dose oestrogen or alternative progesterone – but no clear evidence base for this) –She could elect to continue with her current pill and treat migraine appropriately

8. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE NB Some women experience cyclical (menstrual) migraine, occurring as oestrogen levels fall at the onset of menstruation (or in the ‘gap’ week in women taking the combined contraceptive pill). This variation of migraine is clearly triggered by hormonal changes and may be improved by hormonal manipulation (e.g. perimenstrual oestrogen supplementation or, if the woman is taking the combined contraceptive pill, by changes to the brand of pill or pill taking regime). For details see http://www.cks.library.nhs.uk/migraine/view_ whole_guidance http://www.cks.library.nhs.uk/migraine/view_ whole_guidance

9. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Is it safe for Miss Smith to continue taking the combined oral contraceptive?

10. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Migraine without aura does increase the relative risk of stroke Since the absolute risk of stroke in most women of reproductive age is very low, an individual may consider this small increase in risk to be acceptable If there are other vascular risk factors (increasing age, hypertension, smoking, hyperlipidaemia, obesity, strong family history) this will need to be taken into account when reaching a decision Migraine with aura is associated with about twice the relative risk of stroke compared to migraine without aura and is considered to be a contraindication to use of the combined contraceptive pill

11. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE After discussion, Miss Smith decides to try stopping her combined oral contraceptive pill and to use barrier contraception. Four months later she returns to her GP as her symptoms have not improved. She continues to experience disabling migraines about three times a month and her employers have expressed concern about her sickness record.

12. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE What treatment options are available for the acute treatment of Miss Smith’s migraine?

13. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Acute treatment of her migraine attacks should follow the ‘treatment ladder’ Step 1a – trial of full dose OTC NSAID (e.g. Aspirin or Ibuprofen) with antiemetic to control nausea (e.g. Domperidone or Prochlorperazine –NB- Metoclopramide best avoided in young women in view of risk of dystonic reactions). Treatment started as early as possible with onset of migraine Step 1b – prescription NSAID (e.g. Diclofenac) with antiemetic (NB care needs to be taken in view of her asthma – some patients experience potentially dangerous exacerbation of asthma with NSAIDs – as she has used OTC Ibuprofen with no problems she is unlikely to experience problems with Diclofenac – but she needs to be warned of this possibility and needs to monitor her asthma more closely when taking this medication) Step 2 – consider rectal NSAID and antiemetic if acceptable to patient Step 3 – trial of triptan at onset of headache (if ineffective worth trial of different triptan or formulation as individual response variation)

14. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE Should she take prophylactic treatment and if so what would you prescribe?

15. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE The decision to take prophylactic treatment depends on the severity and frequency of migraines and on patient wishes. As a rule of thumb consider prophylactic treatment if –Disabling migraine >2-3 times a month –Use of acute migraine treatment twice a week or more on regular basis –Less frequent but very prolonged/disabling migraine –Migraine unresponsive to acute treatments (or contraindications to use) Prophylactic treatment will not abolish migraine but should reduce frequency. Prophylactic medication needs to be titrated up to effective dose and consider gradual withdrawal of medication after 4-6 months

16. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 1 st line prophylactic treatments –Beta-blockers e.g. Propranolol, Atenolol, Metoprolol (but contraindicated in Miss Smith because of Asthma) –Amitriptyline – (patient needs to be aware of risk of drowsiness and anticholinergic effects)

17. School of Clinical Medicine School of Clinical Medicine UNIVERSITY OF CAMBRIDGE 2 nd line treatments –Sodium Valproate (need to discuss risk of teratogenicity and consider effectiveness of her current barrier contraception) –Topiramate (on specialist advice only)