GP Trainees-Headache

16th September 2009Lalitha Vaithianathar

Cons. Neurologist, RDH

Headache

• History Taking• Headache Cases• Clinical f’s and Mx of:

- Migraine - Tension type h/a - Medication overuse h/a - Trigeminal Autonomic

Cephalgias

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

Sudden onset Headache

PRIMARY 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

History taking in h/a

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

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

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

Migraine

Migraine

• Migraine Without Aura- common type (80-90%)

• Migraine With Aura -classic type (10-20%)– Subtypes:

• Vertebrobasilar• Hemiplegic

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

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

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

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

Migraine Treatment

BASH (British association for the study of headache) guidelines:

• Rest, sleep if possibleAcute 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

Migraine Treatment

Acute rescue Rx : • Step 1:

– Aspirin (600-900mg) or ibuprofen (400-600mg) 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

Migraine TreatmentAcute 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)

Migraine TreatmentPrevention of migraine (4 attacks/mth)• 1st Line Drug Rx’s

– B-Blockers: atenolol 25-100mg bd; propranolol LA 80-160mg 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 300-1000mg 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)

Tension type h/a

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

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

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 250-500mg bd for 3/52 as one off

(may break cycle)

Trigeminal autonomic cephalgias

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

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

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

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

Summary

• Good history can distinguish between headache types

• Headache management requires a flexible and individualised approach