1. Dublin November 13 th 2011 By Dr. Edward O’Sullivan 13-Nov-2011 1

2. Lifetime ------>90% 1 Year---------> 40% 4.2%----------> G.P. Consultations 30%----------> Neurology Consultations 13-Nov-2011 2

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

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

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

9. PREVALENCE OF MIGRAINE PREVALENCE OF MIGRAINE Lipton RB, Stewart WF. Neurology. 1993. Migraine Prevalence (%) 13-Nov-2011 9

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

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

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

14. 13-Nov-2011 Nausea ------80% Vomiting---- 50% Photophobia Phonophobia Cutaneous Alloydynia 14

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16. 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

17. Need to lie down Personal Social Familial 3-5 days lost Annually Lost Productivity 13-Nov-2011 17

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20. 13-Nov-2011 AuraHeadache 20

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

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

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

24. 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

25. 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

26. 13-Nov-2011 Serotonin 26

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

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

30. 13-Nov-2011 3-5% 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

31. 13-Nov-2011 1% 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

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

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

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

35. 13-Nov-2011 35 History of headaches > 4 years 16-20 days per month Lasting 48 hours Bilateral Occipital Headaches Dull / Aching Mild 4-6 Paracetamol

36. 13-Nov-2011 36 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.

37. 13-Nov-2011 37 20 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

38. 13-Nov-2011 38 Chronic Migraine TREATMENT: 1. Preventative Therapies: Atenolol 25mg + Amitriptyline 25mg ½ nocte 2. Eletriptan 40mg—releif within -2 hours

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