Headache
PRIMARY CARE MANAGEMENT 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+/- antiemetic Eg aspirin 600-900mg +buccastem 3-6mgbd Step two – rectal analgesic +/- antiemetic Eg diclofenac suppositaries+domperidone suppositaries Step 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.