16th September 2009 Lalitha Vaithianathar Cons. Neurologist, RDH GP Trainees-Headache 16th September 2009 Lalitha 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 SECONDARY 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 possible Acute 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 Treatment Acute 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 Treatment Prevention 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