1. Headaches
Jo Swallow
ST1s May 2009

2. Roberta 44yrs, headache
Roberta presents to your surgery on Friday afternoon. She says that she has had terrible migraines most days over the past 3 months.
What important features do you need to elicit in the history
What examination would you like to perform?
?Investigations
?management plan

3. Primary/Secondary Migraine Cluster Tension Medication induced
?secondary to intracranial lesion

4. Migraine periodic headaches with complete resolution between attacks
Sequence may occur:
Prodrome
Aura
Headache
Resolution

5. Prodrome features mood changes coldness or warmth
anorexia or increased appetite
heightened sensitivity to light, sound and smell

6. Aura often consisting of bright specks of light
hemianopia, expanding scotoma, constricted visual fields
aura usually precedes the headache, but may accompany it and usually lasts min
fortification spectra, which are often 'C'-shaped
objects may rotate, oscillate, or 'boil'
simple flashes, specks, and shimmerings

7. Who painted this? Name?

8. Aura

9. Aura

10. Aura 1
Headache follows certain changes that take place in the nerves to the major blood vessels in the head. The aura is due to changes that take place in the cortex, the outer layer of the brain.

11. Aura 2
In experiments with animals, the EEG shows a depression (lowering) of nerve cell activity below a spot on the cortex of the brain that has been stimulated. Surrounding the area of depressed activity is a zone in which nerve cells have become hyperactive. It's thought that a similar pattern of decreased and increased nerve cell activity occurs in the brain of a person with migraine, following the stimulus of a migraine "trigger."

12. Aura cause
When the activity of nerve cells is depressed, there is impairment of function in the part of the body controlled by these cells. For example, there may be a loss of vision or of strength. Increased activity of brain nerve cells may result in flashing lights or tingling in the face and hand. In the experiments with animals, the depression of nerve cell activity slowly spreads beyond the initial spot of stimulation. This phenomenon is called spreading depression. It is preceded by a wave of increased nerve cell activity.

13. Aura cont…
paraesthesiae are the second most common type of aura. Numbness usually starts in the hand, migrates up the arm, then involves the face, lips, and tongue. The leg is sometimes involved. Numbness may follow the paraesthesia. Sensory auras rarely occur alone, and usually follow visual auras
speech disturbances are the third most common

14. Differentiating migraine and tension headache
migraine is therefore a head pain head pain with associated features (contrasting with tension-type headache which is featureless head pain)
migraine is often associated with onset after confrontation to particular triggers

15. Migraine vs. tension boring or squashing, bilateral head pain
Pain throbbing, unilateral head pain worsening of pain with movement vs.
nausea and vomiting, phonophobia or photophobia poss.
boring or squashing, bilateral head pain
No assoc features

16. Migraine triggers
altered sleep patterns (too little or too much sleep may precipitate migraine)
overexertion
skipping meals
changes in stress level - may be too much or too little relaxation
excess of afferent stimuli e.g. bright lights
changes in the weather may precipitate migraine attacks
menstruation
chemical trigger e.g. delayed headache after glyceryl trinitrate or

17. Gastric stasis soluble aspirin 600-900 mg stat in adults
paracetamol 1 g - adult dosage
non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen g daily in divided doses
An anti-emetic such as metoclopramide or domperidone not only relieves nausea that accompanies may migraine attacks but also enhances the efficacy of simultaneously administered oral analgesics
diclofenac suppositories 100mg for pain plus domperidone suppositories 30mg (if vomiting)

18. 2nd line migraine treatment
Sumatriptan is a 5-HT 1 receptor agonist used for the acute treatment of migraine and cluster headache. and as a nasal spray.
Prophylaxis
Atenolol/propranolol
Amitryptilline
Ramipril
Gabapentin

19. Treatment of tension headache
Lifestyle change
Alternative therapies
MEdication
low doses are effective e.g. amitriptyline, initially 10 mg nocte rising if required to mg daily
Consider trial without if asymptomatic > 6months