1. Diagnosis and management of primary headaches-BASH guidelines Aisha Bhaiyat 14 June 2011

2. Aim to cover the following: Red flags Migraines Tension type headache Cluster headaches Medication overuse headaches

3. Classification of headaches Primary - migraines, TTH, cluster Secondary – trauma, vascular, ICP (BIH or tumour, substance or its withdrawal (CO, EtOH, medication), extracranial (acute glaucoma, sinusitis, teeth) Neuralgias - trigeminal

4. Red Flags New/unexpected headache in an individual Thunderclap headache Atypical aura (motor weakness or longer than 1 hour) First aura on starting COCP New onset headache in over 50’s or under 10’s Persistent am headache with nausea Progressive headaches Postural headaches New onset headache in those with PMH of cancer/HIV

5. Consider serious causes Intracranial tumours SAH Meningitis Temporal arteritis Primary angle closure glaucoma Idiopathic intracranial hypertension Carbon monoxide poisoning

6. History Timing-onset, frequency, duration, why present now Character-site, radiation, quality, intensity, associated symptoms Cause-prediposing/trigger, aggravating/relieving, FH Between attacks-well/residual/persisting symptoms. ICE

7. Migraine without aura-diagnosis IHS criteria. At least 5 attack fulfilling the following: Duration- lasting 4-72 hours Character, at least 2 of the following; unilateral, pulsating, mod/severe, worse with physical activity Associations-nausea/vomiting or photophobia/phonophobia Not due to any other secondary cause

8. Migraine with aura-diagnosis Aura-progressive, last 5-60 minutes prior to headache. Hemianopic disturbance/spreading scintillating scotoma. Not blurring or spots. Can include other focal neuroligical symptoms eg parasthesia, dysphasia Consider TIA if new onset in elderly patients Refer to specialist if aura includes motor weakness, persists after resolution of headache or occur daily.

9. Scintillating scotoma

10. Tension type headaches-diagnosis Usually generalised, can be unilateral Pressure/tightness around the head Radiate from the neck Lasts a few hours No associated features

11. Cluster headaches-diagnosis M:F 6:1, over 20’s, smokers Occurs same time each day, last 30-60 mins, 6- 12 wks, every 1-2 years, at the same time of year Intense, unilateral pain Autonomic features: ipsilateral conjuntival injection, lacrimation, rhinorrhoea, blocked nose and ptosis

12. Medication overuse headache- diagnosis Caffeine and codeine are prime causes. Although simple analgesia can be causes. Low doses daily is worse that high dose weekly. Detailed analgesia history. Headache sufferer for years, using analgesia. Headache worse in the morning and with physical activity. Patient requesting stronger and stronger analgesia

13. Physical examination BP-patient expectation, HT, migraine prophylaxis can cause HT Fundoscopy-papilloedema Head and neck for muscle tenderness CNS exam - Not specified in the guidelines Investigations-only if a secondary cause suspected

14. Migraine-management Aim is to control symptoms sufficiently to not impact on patients life ie cure unlikely. Trigger factor avoidance-eat reg, sleep Drug treatment of acute symptoms Prophylaxis

15. Migraine-acute Criteria for progressing to next step: Failure on 3 occassions Step 1: po NSAID +/- po/buccal antiemtic Step 2: pr NSAID +/- pr antiemetic Step 3: antimigraine drugs If step 3 fails-review diagnosis, compliance and how medication is being used. Step 4: Combine step 3 with step 1 or 2 Do not use opiates-gastric stasis; risk of medication overuse headache

16. Antimigraine drugs Triptans PO/Melts/Subcut At the start of headache, whilst mild pain Ineffective during aura Can cause rebound migraine in 20-50% within 48 hours Ergotamine Longer duration of action; Less likely to have rebound migraine More toxic and med overuse headaches

17. CI to step 3 Uncontrolled HT Risk factors for vascular disease Age under 12 years

18. Migraine-prophylaxis Indication-frequent/inadequate control/triptan 10 or more days a month/analgesia 15 or more days a month/triptans or analgesia 2 or more days a wk Drugs should be titrated up slowly (avoid SE) and not deemed ineffective too early; trial should last 6-8/52 Effective drug should be used for 4-6/12 and withdrawal tapered over 2-3/52

19. Migraine prophylax-1 st line B-blockers-atenolol 25-100mg bd, CI asthma/CCF/PVD/depression Amitryptiline 10-150mg when migraine coexist with TTH, sleep probs, chronic pain, or depression

20. Migraine prophylaxis-2 nd and 3rd line Topiramate (acute myopia/glaucoma) 25-50 mg bd Valproate 300-1000mg bd (FBC at starting, and LBP for 6/12) 3 rd line: gabapentin, methysergide (risk of fibrosis), b-blocker + amitryptiline combined

21. Tension type headaches Reassurance Ensure medication is not overused, risk of developing medication overuse headaches. Exercise + relaxation NSAIDS, less than 2/7 per week If frequent, break cycle by giving regular naproxen for 3/52, course not to be repeated If chronic-Amitryptiline Avoid opiates Pain clinics

22. Cluster headaches Reassurance Drugs + oxygen Both symptomatic + prophylaxis required Avoid EtOH and smoking

23. Cluster headaches-drugs Symptomatic: Sumitriptan 6mg s/c, oxygen 10- 15l/min 10-20 mins Prophylaxis:Verapamil (ECG)/prednisalone 60- 100mg od (2-5/7 and reduce by 10mg every 2- 3/7)/ Lithium (serum monitoring)/methysergide (risk- fibrosis)/ergotamine Continue until headache free for 14 day (except steroids) and then gradually reduce.

24. Med overuse headaches Withdrawal Recovery Review the original headache disorder (which may return after recovery from withdrawal) Prevent relapse

25. Med overuse headaches All patients with headache should be educated about medication overuse Withdrawal-symptoms worsen, sick leave for 1-2 wks, good hydration. Ergot/triptan/non opioids stopped abruptly. Withdrawal headache last 2-10/7. May have nausea/vomiting/low BP/Hi HR/sleep probs/anxiety. Opioids slowly-consider referring to drug and etoh services. Withdrawal headache-reg naproxen for 3/52, course not to be repeated.

26. Summary Consider serious causes incl CO poisoning Remember to check BP and fundoscopy Avoid prescribing opioids Advice re lifestyle and risks of med overuse If occurring frequently, consider regular naproxen for 3/52 to break cycle or prophylaxis treatment Consider chronic pain management options Further information www.bash.org.uk