Guidelines for all doctors in the diagnosis and management of Migraine and Tension-Type Headache Writing Committee: T.J. Steiner E.A. MacGregor P.T.G. Davies 2004

Headache in the UK Affects nearly everyone occasionally Is a problem for around 40% of people Is one of the most frequent causes of consultation in both general practice and neurological clinics Represents an immense socioeconomic burden

Migraine in the UK Affects 12-15% of the population Affects 3X more women than men Most troublesome late teens to early 50s Also occurs in children and the elderly

Migraine in the UK An estimated 187,000 attacks every day Almost 90,000 people absent from work or school as a result Annual cost through lost work and impaired effectiveness may be £1.5 billion Despite these statistics migraine seems to be under-diagnosed and under-treated

Tension-type Headache (TTH) Affects up to 80% of people Often referred to as a ‘normal’ or ‘ordinary’ headache by patients Most do not consult a doctor High prevalence results in a similar economic burden to migraine via lost work or reduced working effectiveness 2-3% of adults have chronic TTH (i.e. TTH >15 days per month) Chronic TTH can result in substantial disability and work absence

British Association for the Study of Headache (BASH) Management Guidelines Intended for all doctors who manage headache - in general practice or specialist clinics Provide management strategies supported by specialists in the field Should be incorporated by healthcare commissioners into any agreement for provision of service

British Association for the Study of Headache (BASH) Headache management requires a flexible and individualized approach BASH Guidelines can be tailored to individual clinical circumstances

The International Headache Society Classification The International Headache Society (IHS) classifies headache disorders under primary and secondary conditions

Migraine –Without aura –With Aura Tension-type Headache –Episodic –Chronic Cluster Headache and other trigeminal autonomic cephalalgias IHS Classification Primary Headaches

IHS Classification Secondary Headaches Headache attributed to –Head and/or neck trauma –Vascular disorders –Non-vascular intracranial disorders –A substance or its withdrawal –Infection –Disorder of homeostasis –Disorder of cranium neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures –Psychiatric disorder Cranial neuralgias and central causes of pain Headache unspecified/not classified

*Assuming a condition requiring urgent attention has already been ruled out Patient history The key to diagnosis History is all-important –No diagnostic tests for primary headache Patient diaries can help identify patterns of attacks and aid diagnosis* Different headache types are not mutually exclusive Take a separate history for each headache type In children, migraine and tension-type headache may be less distinct than in adults

Headache history Key questions TIME - Onset, frequency, patterns, duration? CHARACTER - Site, intensity, nature of pain? CAUSES - Predisposing, triggering, aggravating, relieving factors? - Family history? RESPONSE - Patient’s actions and limitations during an attack? - Medications used? INTERVALS - How does the patient feel between attacks? - Concerns, anxieties and fears about attacks?

Migraine Diagnostic Pointers Typically Recurrent episodic headaches with moderate or severe pain May be unilateral and/or throbbing Last from 4 hours up to 3 days Associated with gastrointestinal and visual symptoms Activity is limited and dark/quiet is preferred Free from symptoms between attacks

IHS diagnostic criteria Migraine without aura* An idiopathic recurring headache with: A. At least 5 attacks fulfilling B-D B. Attacks last 4-72 hours C. At least 2 of the following - Unilateral location - Pulsating quality - Moderate or severe pain intensity - Aggravated by routine physical activity D. At least one of the following during an attack - Nausea and/or vomiting - Photophobia and phonophobia E. Not attributed to another disorder * In children, attacks may be shorter; also more commonly bilateral and GI disturbance is more prominent

Diagnosis Migraine with aura Aura precedes headache Symptoms of migraine aura: –Transient hemianopic disturbances prior to headache, lasting minutes (occasionally up to 1 hour) –A spreading scintillating scotoma (patients may draw a jagged crescent) –Other reversible focal neurological disturbances e.g. unilateral paraesthesiae of hand, arm or face Visual blurring and ‘spots’ are not diagnostic Patients may have attacks of migraine with aura and migraine without aura at different times

‘Diagnosis’ by treatment Can be tempting to use the specific anti- migraine drugs as a diagnostic test This approach is likely to mislead –Low sensitivity ‘Triptans’ are at best effective in only three quarters of attacks –Low specificity TTH in migraineurs can respond to triptans

Tension-type Headache (TTH) TTH –Replaces ‘tension headache’ and ‘muscle contraction headache’ –Typically generalized ‘vice like’ or ‘a tight band’ –No nausea or photophobia

Tension-type Headache (TTH) Occasional TTH is seldom disabling (unlike chronic TTH) Both TTH and migraine are aggravated by stress (so can be hard to differentiate) Headache more often than once a week may be a mixture of TTH and migraine Successful management is dependent on recognition and management of each separate headache type

Chronic Daily Headache (CDH) CDH –A descriptive, not diagnostic, term –Headache occurs on more days than not (>50% of the time) over weeks or longer –Affects up to 4% of the population –Accounts for up to 40% of referrals to special headache clinics –Costs the UK economy up to £1 billion per year in lost working time yet is very poorly characterized Headaches occurring every day are generally not migraine (but may co-exist with migraine) CDH includes chronic TTH & Chronic Migraine

Medication Overuse Headache (MOH) Affects an estimated 1 in 50 people First noted with phenacetin and ergotamine Typically results from overuse of OTC analgesics A related syndrome occurs with ‘triptans’ Accurate diagnosis is difficult in the presence of MOH A detailed medication history is essential

Cluster Headache (CH) Formerly known as migrainous neuralgia Generally affects men (ratio 6:1), often smokers, in their 20s or older Typically occurs in bouts for 6-12 weeks every one or two years Attacks typically occur at night, waking the patient 1 to 2 hours after falling asleep, lasting 30 to 60 minutes Pain is intense, probably as severe as renal colic, and strictly unilateral

Physical examination of headache patients Physical examination can reassure patients Optic fundi should always be examined Blood pressure measurement is recommended Examine head and neck for muscle tenderness, especially in tension-type headache Examine jaw and bite Some paediatricians recommend head circumference measurement for children, plotted on a centile chart

Serious cause of headache 1 Intracranial tumours –Rarely produce headache until quite large –Epilepsy is a cardinal symptom –Loss of consciousness should be viewed very seriously –Focal neurological signs are generally present –Diagnosis harder in neurological ‘silent areas’ of the frontal lobes Meningitis –Usually accompanied by fever and neck stiffness –Headache may be generalized or frontal (perhaps radiating to the neck) –Nausea and disturbed consciousness may accompany headache later

Serious cause of headache 2 Subarachnoid haemorrhage (SAH) –Usually, sudden onset of very severe ‘explosive’ headache –Neck stiffness – may take hours to develop –Classical signs and symptoms may be absent in the elderly –Sometimes confused with migraine ‘thunderclap’ headache –Serious consequences of missing SAH call for a low threshold of suspicion Temporal arteritis (TA) –Suspect if new headache in patients over 50 years –Headache accompanied by marked scalp tenderness –Headache persistent but often worse at night –Jaw claudication is highly suggestive of TA

Serious cause of headache 3 Primary angle-closure glaucoma –Rare before middle age –Headache and eye pain can be dramatic or episodic and mild Idiopathic intracranial hypertension –Formerly termed benign intracranial hypertension or pseudotumor cerebri –Rare cause, usually in obese young women –History may suggest raised intracranial pressure –Papilloedema is diagnostic in adults –Diagnosis confirmed by CSF pressure measurement Carbon monoxide (CO) poisoning –Headache is a symptom of sub-acute toxicity –Uncommon but potentially fatal

Migraine Management Overview Aim for effective control of symptoms –A cure is unrealistic Under-treatment is not cost-effective –Results in unnecessary pain and disability –Repeat consultations are expensive Migraine typically varies with time –Needs may change

Migraine Management Overview Four elements to effective migraine management in adults –Correct and timely diagnosis –Explanation and reassurance –Identification and avoidance of pre- disposing/trigger factors –Drug or non-drug intervention Children –Often respond to conservative migraine management –If this fails, most can be managed as adults

Migraine Predisposing Factors Predisposing factors are different from precipitating/trigger factors Five main predisposing factors are recognized –Stress –Depression/anxiety –Menstruation –Menopause –Head or neck trauma

Migraine Trigger Factors Trigger factors are seen in occasional patients and include –Relaxation after stress: weekends/holidays –Change in habit: sleep, travel etc. –Bright lights/loud noise –Diet: alcohol, cheese, citrus fruits, possibly chocolate (but evidence is inconclusive); missed or delayed meals –Strenuous unaccustomed exercise –Menstruation A trigger diary kept by patients can be useful unless causes introspection

Migraine Acute Drugs Five step treatment ‘ladder’ Failure on three occasions is the minimum criterion for moving to the next step

Migraine Acute Drugs 1 Step 1: Oral analgesics ± Antiemetic a) Simple analgesics, preferably soluble –Aspirin or paracetamol or ibuprofen –NOT codeine or dihydrocodeine b) As above or prescription-only NSAID plus prokinetic antiemetic (metoclopramide or domperidone) Contraindications: Aspirin not recommended for children under 16 Metoclopramide not recommended for children or adolescents

Migraine Acute Drugs 2 Step 2: Parenteral Analgesic ± Antiemetic Diclofenac suppositories Plus Domperidone suppositories Contraindications: Peptic ulcer or lower bowel disease Diarrhoea Patient non-acceptance

Migraine Acute Drugs 3(i) Step 3: Triptans Marked inter-patient variation in response – see which suits the patient best Ineffective if taken before onset of headache Some experts suggest adding metoclopramide or domperidone Symptoms often relapse within 48 hours Contraindications: Uncontrolled hypertension Risk factors for CHD or CVD Children under 12 years

Migraine Acute Drugs 3(ii) Step 3: Ergotamine Toxicity and misuse are potential drawbacks Contraindications: Ergotamine is not an option if triptans are contraindicated and should not be taken concomitantly with a triptan Beta-blocker therapy Not advised for children

Migraine Acute Drugs 4 Step 4: Combinations Steps 1+3 may be helpful, followed by Steps 2+3 Self-injected diclofenac may be tried

Migraine Emergency Treatment Emergency treatment at home NOT pethidine Intramuscular diclofenac and/or Intramuscular chlorpromazine –Antiemetic and sedative

Migraine Repeated Relapse Consider naratriptan, eletriptan or frovatriptan Ergotamine –Prolonged duration of action Diclofenac or tolfenamic acid may be used –Pre-emptively if relapse is anticipated

Migraine Prophylactic Drugs Prophylactic therapy is used (in addition to acute therapy) to reduce the number of attacks when acute therapy alone gives inadequate symptom control Criteria for choice of prophylactic drug based on –Evidence of efficacy –Comorbidity and effect of drug –Contraindications, including risk of pregnancy –Frequency of dosing: once daily dosing is preferable

Migraine Prophylactic Drugs 1 First-line –Beta-blockers (atenolol,metoprolol, propranolol, bisoprolol) if not contra-indicated –Amitriptyline – when migraine co-exists with TTH Another chronic pain condition Disturbed sleep Depression

Migraine Prophylactic Drugs 2 Second-line –Sodium valproate –Topiramate Evidence for sodium valproate is reasonable and clinical usage is extensive Evidence for topiramate is very good but clinical usage is as yet limited

Migraine Prophylactic Drugs 3 Third-line –Gabapentin –Methysergide –Beta-blockers and amitriptyline (in combination)

Migraine Prophylactic drugs 4 Other options (limited efficacy) –Pizotifen –Verapamil –SSRIs

Migraine Menstrual attacks Perimenstrual prophylaxis –Non-hormonal Mefenamic acid - first-line in migraine occurring with menorrhagia and/or dysmenorrhoea –Oestrogen If the women has an intact uterus and is menstruating regularly, no progestogens are necessary Combined oral contraceptives –Migraine without aura in pill-free interval may resolve with a more oestrogen-dominant pill –Not recommended for women with migraine with aura

Migraine HRT Migraine and hormone replacement therapy The menopause itself commonly exacerbates migraine Symptoms can be relieved with HRT No evidence that risk of stroke is elevated or reduced by use of HRT in women with migraine Some women on HRT find migraine worsens –Often solved by reducing dose and/or changing to non-oral formulation

Migraine Non-drug Intervention Improving physical fitness Physiotherapy (but no evidence) Acupuncture Psychological therapy –Relaxation –Stress reduction –Coping strategies –Biofeedback

Tension-type Headache (TTH) Management Infrequent episodic TTH (<2 days/week) Reassurance Symptomatic treatment –Aspirin, paracetamol or ibuprofen –Codeine and dihydrocodeine should be avoided

Chronic TTH Symptomatic treatment may give short- term relief but is inappropriate long-term Consider a course of naproxen –May break the cycle –May stop overuse of analgesics Amitriptyline is the prophylactic of choice Tension-type Headache (TTH) Management

Non-drug interventions Regular exercise Physiotherapy Stress-coping strategies Acupuncture

Co-existing Headaches Management Restrict symptomatic medication –Max 2 days per week Prophylaxis for migraine coexisting with episodic TTH –Amitriptyline –Sodium valproate

BASH Guidelines Effects of Implementation Improve diagnosis Increase the number of patient with migraine using triptans Reduce misuse of medication, including triptans Reduce the need for specialist referral Improve the overall effectiveness of headache management Reduce inappropriate treatment Improved treatment for each patient Improve outcome Reduce iatrogenic illness Reduce disability

BASH Guidelines Effects of Implementation Initially increases the no. of consultations per patient BUT Reduces the overall number of consultations Raises expectations, especially amongst those with migraine, leading to more patients consulting BUT Reduces the overall burden of illness, with savings elsewhere

Audit Judging Effectiveness Aims of Audit –To measure direct treatment costs Consultations, referrals and prescriptions –To measure headache burden Before and after implementation of BASH guidelines Migraine Disability Assessment (MIDAS) may be useful in the audit process –A self-administered questionnaire –Measures the adverse effect of headache on work and social activities over the preceding 3 months