Headache

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Headache

• Lawrence Pike

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• Tension headache
• Chronic daily headache
• Analgesic overuse / rebound headaches
• Rare causes

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Tension headache

• Tension - type headache is most commonly episodic
  (occurs less than 15 times per month). It is
  defined as chronic when it occurs 15 or more
  times per month for a minimum of 6 months.
• Chronic tension headache is the commonest form of
  chronic and recurrent headache and often
  associated with a sustained contraction of
  skeletal muscle of the scalp, jaw and neck. This
  is sometimes associated with anxiety and
  emotional stress.
• Precipitating factors for tension headache
  include psychological, social and emotional
  factors, minor head injury and CNS infection
  (e.g. post viral meningitis).

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Chronic daily headache

• Chronic daily headache (overlaps with chronic
  tension headache) is a descriptive term used when
  there is headache occurring on more days than not
  or for more than 50 of the time. There is often
  association with sleep disturbance, anxiety and
  analgesic overuse. Family history is positive in
  90 of patients. The cause is often analgesic
  overuse.

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Analgesic overuse / rebound headaches

• Usually result from analgesic overuse in chronic
  headache sufferers, most commonly with the use of
  opioids or ergotamine for the management of
  migraine or chronic tension headache.
• It may also occur when other analgesics are used
  over-frequently for headache.
• A chronic daily headache develops after long term
  continuous or overuse of the offending drug and
  cessation of treatment leads to withdrawal
  symptoms (primarily headache).

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Rare Causes

• Benign cough headache
• Ice-cream' headache
• Benign Exertional Headache
• Headache associated with sexual activity.

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Incidence

• Over 95 of the population suffer from
  occasional headache.
• A much smaller proportion consult their GP with
  headache.
• Tension headache and chronic daily headache are
  more common in women and those with a positive
  family history
• 3 of the population suffer from chronic daily
  headache.
• Up to 1 in 50 people suffer from analgesic
  overuse / rebound headache.
• Headache has a significant functional impact at
  work, home and school.

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Examination

• CNS examination including cranial nerves and
  mental state is likely to be normal in tension
  and other non-serious headache, but is essential
  in order to exclude more serious causes.
• Fundoscopy should always be performed to exclude
  hypertension (also check blood pressure) and
  papilloedema. Steiner 1997
• Palpation of the face and neck to exclude local
  causes.
• Exclude meningeal irritation (neck stiffness and
  Kernig's sign).

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Management

• Identification and exclusion of precipitating
  factors
• Headache calendar has been found effective in
  identifying possible aetiological factors
• Cognitive behavioural therapy with a view to
  improving coping strategies is sometimes
  effective
• Discussion with regard to lifestyle changes in
  order to reduce stress and anxiety, may be of
  value.
• Relaxation therapies and postural advice are
  effective if used appropriately.

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Drug Management

• Paracetamol, aspirin and other NSAIDs are
  effective in the treatment of headache.
• Codeine should be used with caution because of
  the increased chance of causing analgesic rebound
  headache.
• Low dose combination codeine preparations have
  been shown to be of no greater efficacy than
  paracetamol alone.
• High dose codeine (30mg) may be used for patients
  with severe headache as it is an effective
  painkiller for severe pain but this must be short
  term (less than one week) only.

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Management cont.

• Analgesic overuse rebound headache is treated by
  stopping the analgesic. An alternative analgesic
  used at recommended frequencies and doses can be
  helpful
• In severe, chronic tension headache, prophylaxis
  with tricyclic antidepressants and betablockers
  if there are migraine-like symptoms may be used
• Acupuncture there is little supportive evidence
  of its benefit