Headache

HEADACHES

PRIMARY CARE MANAGEMENT

Headaches-overview

Primary headaches -Migraine -tension type -cluster headache/cephalgias -Others

Headache classification

Secondary headaches- Trauma Cranial/ cervical vascular disorder Substance or its withdrawl Infection Homeostasis related Neck , sinuses,eyes,nose, teeth Anxiety/somatisation

Headache classification

Neuralgias/other headaches Eg cranial neralgias, trigeminal neuralgia,

atypical facial pain

Headaches

Affect 40% of UK population Migraine- 15% of population. Females:males 3:1 Tension headaches- 80% of population Cluster headache 1 in 200

MIGRAINE

Migraine

Migraine management

Look at predisposing factors -stress,

fatigue,depression,anxiety,menstruation, menopause, head/neck trauma.

-trigger factors-dietary (20%), relaxation, travel, missing meals/sleep, bright lights, noise, strenuous exercise, mensruation.

Migraine

Duration (hours3 days) Without aura in 2/3rd -unilateral, pulsating,

moderate/severe intensity, aggravated by exercise, nausea/vomiting. Photophonophobia

With aura in 1/3rd- spreading scintillating scotoma, unilateral paraesthesia, dysphasia

Migraine-drug intervention

Step one- simple analgesic+/- antiemeticEg aspirin 600-900mg +buccastem 3-6mgbd

Step two – rectal analgesic +/- antiemeticEg diclofenac suppositaries+domperidone

suppositariesStep three – triptans-use at onset of pain, not

aura. Some rebound of symptoms in 20-50% of patients within 48 hours.

Triptans

Sumatriptan 50-100mg Zolmitriptan 2.5mg then rpt after 2 hours (not

children) Rizatriptan 10mg (equiv sumatriptan 100mg) Almotritan 12.5mg-HIGH EFFICACY. COST

EFFECTIVE

Migraine prophylaxis

Ineffective for medication overuse headaches Use for 4-6 months-taper off over 2-3 weeks. Agents: betablockers, TCAD, pizotifen,

gabapentin, lisinopril Other agents-topiramate, sodium valproate,

clonidine Non drug therapies

Tension headache

Tension headaches

Chronic tension type headache:-

-more than 15 days per month

- often daily

-often stress/lifestyle related

Tension headaches

Episodic tension-type headache-

-may be unilateral but tend to be generalised

- pressure/tightness

- often spreads from neck

-stress related or related to cervical/cranial musculoskeletal anomalies

Tension headache management Lifestyle changes Regular exercise Drug treatments-acute-aspirin 600-900mg,

ibuprofen 600mg, naproxen 250-500mg, paracetamol 500mg-1g

Prophylaxis-amitriptyline, nortriptyline, propranolol, SSRIs

Medication overuse headaches Affects 1 in 50 adults Females:males 5:1 First noted with phenacetin/ergotamine More common with aspirin/

NSAIDs/paracetamol/codeine/DF118 Can take several weeks to resolve after

medication withdrawl Key feature-pre-emptive use of analgesia

Medication overuse headaches-cont. Low doses daily carry larger risk than higher

doses weekly Esp common if using simple analgesia more

days than not per month Using triptans, codeine >10days per month Worse on awakening in the morning Worse after physical exertion

Medication withdrawl headache-treatment Stage one-abrupt withdrawl most effective-Sx

will worsen in days 3-7. Stage 2-recovery from MOH Stage 3- review and assess the underlying

primary headache disorder Stage 4- prevent relapse Failure to withdraw- naproxen

250mgtds/500mg bd, tcad.

References

Mentor/GP notebook BASH (British Association for the Study of

Headaches)-guidelines. www.bash.org.uk Neurological Differential diagnoses. Batten,

J. 2nd edition.