Dublin November 13 th 2011 By Dr. Edward O’Sullivan 13-Nov

Lifetime >90% 1 Year > 40% 4.2% > G.P. Consultations 30% > Neurology Consultations 13-Nov

Primary or Benign Tension Type Headache Migraine With or Without Aura Chronic Daily Headache Medication-Overuse- Headache Sinus Headache Cluster Headache Chronic Paroxysmal Hemicrania 3

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Site Frequency Duration Onset Character Severity Exacerbating / Relieving Factors Neck Stiffness Exacerbating / Relieving factors Impact 5

13-Nov-2011 Mental State Neck Stiffness Inspection Tone Power Co-Ordination Sensation Reflexes Planter Response 6

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Bilateral Frontal Headache Mild Tightness / Dull / Aching Duration: 30 minutes to 1 week Muscle tenderness Mild photophobia 8

PREVALENCE OF MIGRAINE PREVALENCE OF MIGRAINE Lipton RB, Stewart WF. Neurology Migraine Prevalence (%) 13-Nov

10

13-Nov-2011 Transient 5-60 minutes Focal Reversible Visual, Sensory, Motor and Dysphasia 11

13-Nov-2011 Sensory Parasthesia 1. Pins and Needles 2. or Numbness Migratory Dysphasia Motor weakness 12

13-Nov-2011 At least 5 attacks Duration: 4-72 hours Unilateral Headaches Throbbing and Pounding Exacerbated by movement Severe. 13

13-Nov-2011 Nausea % Vomiting % Photophobia Phonophobia Cutaneous Alloydynia 14

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13-Nov-2011 Identifiable in 30% Dietary Alcohol Stress Missed meals, Overtiredness, Lack of sleep Menstrual Cycle Combined Oral Contraceptives Strong odours Environmental factors 16

Need to lie down Personal Social Familial 3-5 days lost Annually Lost Productivity 13-Nov

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13-Nov-2011 AuraHeadache 20

13-Nov-2011 Reassurance Headache Diary Avoidance of Trigger Factors Acute Therapies Preventative Therapies Non-Drug Therapies 21

13-Nov-2011 Stress: 1. Psychological 2. Missed Meals 3. Overtiredness 4. Lack of Sleep Promote Exercise 22

13-Nov-2011 Rapid and Complete Headache relief Consistant in response Relief of associated symptoms Free of side effects Cost 23

13-Nov-2011 TREAT EARLY IN ATTACK: Paracetamol Paracetamol / Codiene Analgesic / Caffiene Aspirin N.S.A.I.D’s Triptans Limit use of acute agents to twice weekly. 24

13-Nov-2011 Mode of action: anti- prostaglandin activity Take as early as possible Anti-nausea agents:domperidone Route of administration Recurrence – 40%-- repeat the dose 25

13-Nov-2011 Serotonin 26

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13-Nov-2011 > 2 attacks per month Unresponsive to acute therapies Reduction in frequency, severity and duration of attacks Evaluate after 3 months 28

13-Nov-2011 B-Blockers: propanolol; atenolol Tricyclic Antidepressants : Amitriptyline Anti-convulsants : topiramate, sodium valproate 5 HT3 Antagonists:Pizotifen Calcium Antagonists:Flunarizine 29

13-Nov % population > 15 days per month > 4 hours duration Present > 4 months Past history of Tension Type Headaches or Migraine Co-Morbidity: Anxiety or Depression Medication-Overuse- Headache 30

13-Nov % of Adult Population > 25% of patients attending Headache / Migraine Clinic Triptan Use: > 10 days per month (18 doses/month) Ergot Preparations (37 doses / month) Simple Analgesics (114 doses per month) 1.7 Years to onset 2.7 Years to onset 4.8 Years to onset 31

13-Nov-2011 Migraine Patients Particularly Vulnerable Cutaneous Alloydynia Periphereal Sensitization Central Sensitization 32

13-Nov-2011 ‘Medication Containing Codiene, Caffiene or Sedatives should be restricted’ for acute migraine attacks Risks: 1. Habituation 2. Dependence 3. Tolerance 33

13-Nov-2011 Limit the use of Acute therapies: Consider:N.S.A.I.D’s Detoxification programme Preventative therapies Non-drug therapies 34

13-Nov History of headaches > 4 years days per month Lasting 48 hours Bilateral Occipital Headaches Dull / Aching Mild 4-6 Paracetamol

13-Nov Chonic Tension Type Headache Medication-Overuse- Headache TREATMENT: 1. Stop Analgesics 2. Commence Amitriptyline 10-25mg nocte 3. Naproxyn 250mg prn 4. Review 3 months later- Headache free.

13-Nov year old female—5 year history of frequent headache. Daily x 2 years Unilateral Right Sided Headaches. Severe—2 days per week. Photophobia. Cutaneous Alloydynia Med: nil

13-Nov Chronic Migraine TREATMENT: 1. Preventative Therapies: Atenolol 25mg + Amitriptyline 25mg ½ nocte 2. Eletriptan 40mg—releif within -2 hours

13-Nov-2011 Migraine for many years: On Meeting Dr.Nielsen 39