Esther TomkinsEsther TomkinsClinical Nurse SpecialistClinical Nurse Specialist

Headache/MigraineHeadache/MigraineBeaumont HospitalBeaumont Hospital

Facts / MigraineFacts / Migraine

>500,000 sufferers – Ireland>500,000 sufferers – Ireland >6 million sufferers in UK>6 million sufferers in UK One of the most frequent causes of One of the most frequent causes of

consultation both in general practice consultation both in general practice and at neurological clinicsand at neurological clinics

3:1 women to men3:1 women to men Disabling effect – WHO 19Disabling effect – WHO 19thth /12 /12thth

leading cause of disability leading cause of disability

DiagnosisDiagnosis

History is all importantHistory is all important No diagnostic testsNo diagnostic tests Takes time!Takes time!

Correct DiagnosisCorrect Diagnosis

Secondary Cause – eliminate red Secondary Cause – eliminate red flagsflags

Reassurance – stroke / brain tumourReassurance – stroke / brain tumour Worry! – Tumour, Meningitis, Worry! – Tumour, Meningitis,

Subarachnoid haemorrhage, Giant Subarachnoid haemorrhage, Giant cell arthritis, Idiopathic intracranial cell arthritis, Idiopathic intracranial hypertensionhypertension

QuestionsQuestions

Past history – Childhood, travel sicknessPast history – Childhood, travel sickness Medication history (acute/preventive tried)Medication history (acute/preventive tried) Frequency and duration of headacheFrequency and duration of headache Day’s of mild headacheDay’s of mild headache Different headache typesDifferent headache types Location of pain Location of pain Intensity of painIntensity of pain AuraAura

Associated symptomsAssociated symptoms What does the patient want to do when What does the patient want to do when

they have a headache?they have a headache? Worsens on head movementWorsens on head movement Eye tearing, Ear ringing, Nasal congestionEye tearing, Ear ringing, Nasal congestion Neck stiffness / balanceNeck stiffness / balance Family linkFamily link TriggersTriggers

Different types of headacheDifferent types of headache

MigraineMigraine Tension type headacheTension type headache Chronic Daily HeadacheChronic Daily Headache Medication Overuse HeadacheMedication Overuse Headache Cluster Headache Cluster Headache

What causes migraine?What causes migraine?

2 subtypes migraine with and 2 subtypes migraine with and without aurawithout aura

Neuronal – disorder that primarily Neuronal – disorder that primarily originates from neurological changes originates from neurological changes in brain chemistryin brain chemistry

Secondary – blood vessels constrict Secondary – blood vessels constrict and then swelland then swell

Neurotransmitter - serotonin Neurotransmitter - serotonin

MigraineMigraine

Unilateral HeadacheUnilateral Headache Pulsating characterPulsating character Photophobia, phonophobia, Photophobia, phonophobia,

osmophobiaosmophobia NauseaNausea VomitingVomiting 4-72 hours4-72 hours

Aura – what causes it?Aura – what causes it?

Cortical spreading depressionCortical spreading depression Cortex – controls vision / sensesCortex – controls vision / senses VisualVisual Paraesthesia / pin’s and needlesParaesthesia / pin’s and needles DysphasiaDysphasia Aura without headache!Aura without headache!

What can trigger my migraine?What can trigger my migraine?

StressStress MenstruationMenstruation MenopauseMenopause Head or neck traumaHead or neck trauma Change in habit – missing meals, Change in habit – missing meals,

missing sleep, sleeping inmissing sleep, sleeping in Bright lights, loud noiseBright lights, loud noise Strenuous exerciseStrenuous exercise

Can chocolate trigger my migraine?Can chocolate trigger my migraine?

Premonitory symptomsPremonitory symptoms Cravings sweet or savouryCravings sweet or savoury Keep a diary!!!!Keep a diary!!!!

Acute Drug TherapyAcute Drug Therapy

General rule/Combined with rest and General rule/Combined with rest and sleep!sleep!

Over the counterOver the counter Anti-emetic –“pro kinetic” effectAnti-emetic –“pro kinetic” effect Aspirin/ metoclopramide / Aspirin/ metoclopramide /

domperidonedomperidone NSAID’S – Difene, NaproxenNSAID’S – Difene, Naproxen TriptansTriptans

What are Triptan’s?What are Triptan’s?

Work on serotonin receptorsWork on serotonin receptors Stop swell in blood vessels / stop release Stop swell in blood vessels / stop release

of inflammatory substancesof inflammatory substances Effective in approx 70% of patientsEffective in approx 70% of patients Use at right time, right dose and Use at right time, right dose and

formulation, (too early or too late)formulation, (too early or too late) Try different types – 3 separate attacksTry different types – 3 separate attacks Side effects – chest tightness / throatSide effects – chest tightness / throat 22ndnd dose in 24 hours dose in 24 hours

Preventive MedicationPreventive Medication

Helps to reduce the number of attacksHelps to reduce the number of attacks Also can reduce the severity of migraine Also can reduce the severity of migraine

attacksattacks Side effectsSide effects Titration of dosesTitration of doses Anti-depressantsAnti-depressants Amitriptyline, Sibellium, TopirimateAmitriptyline, Sibellium, Topirimate 6-9 months 6-9 months

What is Medication Overuse?What is Medication Overuse?

Treating migraine most days!Treating migraine most days! Number of days every month that Number of days every month that

painkillers are taken is all importantpainkillers are taken is all important >6-8 days per month>6-8 days per month Stop painkillers!Stop painkillers! Introduce preventiveIntroduce preventive Greater occipital nerve block an Greater occipital nerve block an

optionoption

Chronic Daily HeadacheChronic Daily Headache

Headache > 15 days per monthHeadache > 15 days per month Transformed migraineTransformed migraine

Oral contraceptive pill?Oral contraceptive pill?

Oestrogen ok in generalOestrogen ok in general Combined oral contraceptive drugCombined oral contraceptive drug COC – AURA - SmokeCOC – AURA - Smoke Progesterone only pill favouredProgesterone only pill favoured

Pregnancy?Pregnancy?

Most migraine improves during Most migraine improves during pregnancy!pregnancy!

Role of clinical nurse specialist!Role of clinical nurse specialist!

EducatorEducator Clinical work at Migraine ClinicClinical work at Migraine Clinic Nurse prescriberNurse prescriber Improve access to headache serviceImprove access to headache service Telephone advice and triage of Telephone advice and triage of

patients into servicepatients into service Link with Migraine Ass of IrelandLink with Migraine Ass of Ireland