1. Headache

2. PRIMARY CARE MANAGEMENT
HEADACHES
PRIMARY CARE MANAGEMENT

3. Headaches-overview Primary headaches -Migraine -tension type
-cluster headache/cephalgias
-Others

4. Headache classification
Secondary headaches-
Trauma
Cranial/ cervical vascular disorder
Substance or its withdrawl
Infection
Homeostasis related
Neck , sinuses,eyes,nose, teeth
Anxiety/somatisation

5. Headache classification
Neuralgias/other headaches
Eg cranial neralgias, trigeminal neuralgia, atypical facial pain

6. Headaches Affect 40% of UK population Migraine- 15% of population.
Females:males 3:1
Tension headaches- 80% of population
Cluster headache 1 in 200

7. MIGRAINE

8. Migraine

9. 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.

10. Migraine Duration (hours3 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

11. Migraine-drug intervention
Step one- simple analgesic+/- antiemetic
Eg aspirin mg +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.

12. 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

13. 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

14. Tension headache

15. Tension headaches Chronic tension type headache:-
-more than 15 days per month
- often daily
-often stress/lifestyle related

16. 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

17. Tension headache management
Lifestyle changes
Regular exercise
Drug treatments-acute-aspirin mg, ibuprofen 600mg, naproxen mg, paracetamol 500mg-1g
Prophylaxis-amitriptyline, nortriptyline, propranolol, SSRIs

18. 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

19. 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

20. 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.

21. References Mentor/GP notebook
BASH (British Association for the Study of Headaches)-guidelines.
Neurological Differential diagnoses. Batten, J. 2nd edition.