Headache diagnosis and treatment : now and the future Paul Rolan MBBS MD FRACP FFPM DCPSA Professor of Clinical Pharmacology Senior Consultant, Pain Management Unit, RAH

Headache in 99.9% of people with headache there is no sign of tissue damage injuring the brain itself does not cause pain – it causes altered brain function however the membrane and blood vessels of the brain are very pain sensitive

Headache: causes Primary (99%+) Tension – type69 Migraine16 Stabbing2 Exertional1 Cluster0.1 Due to something else (<1%) Systemic infection63 Head injury4 Vascular / bleeding1 Brain tumour0.1

Headache diagnosis almost entirely on the patients story tests, scans etc rarely helpful.

Headache: history How old were you when the headaches started? How often do they come? Do they come in relationship to anything else? At what time do they come on? How do they start? Where is the pain? How long does it last? How bad is it? Are there other symptoms? Does anything bring it on? What helps? How long does it last?

Pattern recognition pick the odd one out

Tension-type Headache Frequency chronic often daily Painmild-moderate pressure, tightness Duration30 mins - 7 days Locationboth sides whole head and neck Symptomsno light / sound sensitivity no aura Typical patient : any

Tension-type headache now thought to be due to increased brain sensitivity to normal sensory inputs few effective treatments : we are trialling a non-drug treatment

Migraine (“half-head”) Frequency1-2/year- 2-3/week Pain moderate - severe pulsating, throbbing Duration4 hrs - 3 days Locationusually one sided (but side can swap between attacks) Symptomsaura nausea, vomiting sensitive to light, sound, smells

Typical migraine patient onset often as child / teenager / young adult but can start at any age 2-3 x more common in women than men typical patient : young woman (15% of all young women)

What happens during a migraine?

Migraine cause cause unknown but strongly inherited a lower threshold to spontaneously produce symptoms as if the head and brain had been injured many effective treatments

Triggers foods : spices, wine, chocolate, citrus food additives : monosodium glutamate sleep : both too much and too little stress : mainly offset female hormones : fluctuating or falling oestrogen

Migrainous Aura

Medication overuse headache headache made WORSE by pain killers only occurs in people who already had headache mainly due to codeine-containing medicines or stronger morphine-like drugs need to stop responsible medicines : easier said than done we are trialling a new treatment for this

Cluster Headache Frequencyclusters – every time each year or season; then free Painexcruciating penetrating, boring continuous, non-throbbing Duration15mins-3 hrs; same clock time each day (2am); several episodes / day LocationALWAYS the same side Symptomswatering eyes nasal stuffiness, runny nose red eye, swollen eyelids sweating Typical patient : middle aged male smoker

Cluster Headache

Trigeminal Neuralgia VERY short (<1 sec) severe pain Knife-like Local triggering : eating etc Typical patient : middle aged / elderly woman

Other headaches Paroxysmal hemicrania “SUNCT” –short lasting neuralgiform;conjunctival injection, tearing Stabbing headaches After head injury / head surgery Sexual headaches Altitude sickness

Treatment Explanation, set realistic objectives Lifestyle change Treatment of the attack Treatment to reduce attack frequency

Treatment of the attack 1General pain relievers 2Migraine-specific treatments - triptans and ergots 3Cluster specific treatment - oxygen - triptans

General pain relievers : migraine, tension aspirinparacetamolibuprofencodeinetramadol Fast? ✔✔✔✔ Safe? ✔✔ OK for long term? ✖✔✔✖✖✖✖ Not suitable : dextropropoxyphene “Doloxene; Di-Gesic” morphine, pethidine Additives : metoclopramide (nausea) caffeine

Triptans : Imigran, Zomig, Naramig, Maxalt, Relpax FOR can be very effective : migraine, cluster (NOT tension) tablets, wafers, nasal spray, injection AGAINST feel strange, chest pain expensive, small supply overuse makes headaches more frequent constrict blood vessels

Ergots : migraine, cluster FOR can be very effective when others fail nasal spray, suppository injection AGAINST hard to get overuse causes poor circulation and more headache not for tension

Preventative drugs “mixed bag” of drugs used for other conditions found to be effective in headache usually by chance usually for high blood pressure, depression, epilepsy all work in somebody ; none works in everybody generally reduce frequency but do not change attacks key to success : trial and error : persist need to start at low dose and increase until effective or not tolerated about 50 % of patients will get 50% or more reduction in attacks

Main migraine preventers Effectiveness Tolerability / safety GoodFairPoor Goodpropranololverapamil Botox Fairamitriptyline topiramate valproate pizotifen ibuprofen Poormethysergide

Tension preventers Effectiveness Tolerability / safety GoodFairPoor Good Fairamitriptylineibuprofen Poor

Cluster preventers - balance of effectiveness and safety / tolerability Effectiveness Tolerability / safety GoodFairPoor Goodverapamil Fairtopiramate Poormethysergide steroids lithium

Non drug Herbal feverfew – no butterbur – possibly Manual therapies physiotherapy – caution acupuncture – no Electrical occipital nerve stimulation : possibly Closure of hole in heart - no

In the pipeline

“vaccination” for migraine new classes of drugs

Our research we are trialling a non-drug electrical therapy for tension- type headache we are trialling a completely new drug approach to medication overuse headache we may be trialling new agents for migraine in the near future