Hot Topics Headaches

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Hot Topics - Headaches
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Introduction

• Problematic 40 UK pop
• Migraine occurs in 12-15 UK pop
• Estimated 187,000 attacks daily
• 75 report disability at least sometimes
• 90,000 absenteeisms work / school daily
• Lost work / impaired effectiveness 1.5 bill. per
  year

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Headache classification - Primary

• 1. Migraine, including
• 1.1 Migraine without aura
• 1.2 Migraine with aura
• 2. Tension-type headache, including
• 2.1 Episodic tension-type headache
• 2.2 Chronic tension-type headache
• 3. Cluster headache and chronic paroxysmal
  hemicrania
• 4. Miscellaneous headaches unassociated with
  structural lesion

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Headache classification - Secondary

• 5. Headache associated with head trauma,
  including
• 5.1 Acute post-traumatic headache
• 5.2 Chronic post-traumatic headache
• 6. Headache associated with vascular disorders,
  including
• 6.3 Subarachnoid haemorrhage
• 7. Headache associated with non-vascular
  intracranial disorders, including
• 7.1.1 Benign intracranial hypertension
• 7.3 Intracranial infection
• 7.6 Intracranial neoplasm

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Headache classification - Secondary

• 8. Headache associated with substances or their
  withdrawal, including
• 8.1.4 Acute alcohol induced headache
• 8.2.1 Chronic ergotamine induced headache
• 8.2.2 Chronic analgesics abuse headache
• 8.3.1 Alcohol withdrawal headache (hangover)
• 9. Headache associated with non-cephalic
  infection
• 10. Headache associated with metabolic disorder

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Headache classification - Secondary

• 11. Headache or facial pain associated with
  disorder of cranium, neck, eyes, ears, nose,
  sinuses, teeth, mouth or other facial or cranial
  structures, including
• 11.2.1 Cervical spine
• 11.3.1 Acute glaucoma
• 11.5.1 Acute sinus headache
• 12. Cranial neuralgias, nerve trunk pain and
  deafferentation pain, including
• 12.1.4.1 Herpes zoster
• 12.2 Trigeminal neuralgia
• 13. Headache not classifiable

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Pathophysiology of Pain

• Release of vasoactive substances (e.g., substance
  P, calcitonin-gene related peptides and
  neurokinin A) from trigeminal nerve fibers
  induces a sterile inflammatory reaction around
  the blood vessels at the base of the brain and in
  the blood vessels of the dura and pia.
• This "neurogenic inflammation" may be
  accompanied by vasodilation and is triggered by
  nerve impulses originating in the caudal
  trigeminal nucleus.
• Specific abortive agents for migraine such as
  sumatriptan (Imigran) and ergotamine can reverse
  this neurogenic inflammation. This effect is
  probably mediated by interaction with specific
  serotonin receptors (5-HT1D).
• Stimulation of inhibitory (5-HT1) serotonin
  receptors is thought to turn off neurogenic
  inflammation, whereas activation of the
  excitatory (5-HT2) serotonin receptors can lead
  to migraine. Many medications used for migraine
  prophylaxis work by blocking 5-HT2 receptors.

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Diagnosing Headache

• History, history, history (Diary)
• Site
• Origin
• Character
• Radiation
• Associated symptoms
• Timing
• Exacerbating and relieving
• Severity
• State of health between attacks

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Examination

• Blood pressure
• Brief but comprehensive neurological examination
• Optic fundi
• Head and neck ROM
• Investigations rarely contribute if Hx and Ex
  suggest no underlying cause

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Important Headaches

• Migraine
• Tension-type headache
• Cluster headache
• Medication overuse headache

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Causes headaches not to be missed!

• Intra-cranial tumours
• Menigitis
• Subarachnoid haemorrhage
• Temporal arteritis
• Primary angle closure glaucoma
• Idiopathic intracranial hypertension
• Subacute carbon monoxide poisoning
• (Errors of refraction are over estimated!)

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Migraine

• Moderate or severe pain, which may be unilateral
  or throbbing
• Lasts hours to 2-3 days
• Aggravated by routine activity
• Associated with nausea and sometimes vomiting
• Accompanied by photophobia and phonophobia
• Attacks occur between once a week and once a year
  (median one per month)
• One third always have an aura or less commonly a
  reversible focal neurological disturbance

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Migraine
Typical visual aura spreads across the visual
field (1-9 left) over about 30 minutes. Patients
can draw their visual aura (above) Representation
of a scintillating scotoma is pathognomonic of
migraine
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IHS migraine diagnostic criteria (without aura)

• An idiopathic, recurring headache disorder with
  
• A At least 5 attacks fulfilling B-D
• B Headache attacks lasting 4-72 hours
• C Headache having at least two of the following
  characteristics
• 1. Unilateral location
• 2. Pulsating quality
• 3. Moderate or severe intensity
• 4. Aggravation by routine physical activity

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IHS migraine diagnostic criteria (without aura)

• D During headache at least one of the following
• 1. Nausea and/or vomiting
• 2. Photophobia and phonophobia
• E At least one of the following
• 1. History and examination do not suggest any
  condition to which the headache may be secondary
• 2. History and/or examination do suggest such a
  condition, but investigation has excluded it
• 3. Such a condition exists, but migraine did not
  begin in temporal relation to it

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Migraine

• Six elements of good management of migraine in
  primary care
• Correct and timely diagnosis
• Explanation and appropriate reassurance
• High but realistic objectives, agreed by doctor
  and patient
• Identification of predisposing or trigger factors
  and how to avoid them
• Intervention (drug or non-drug, or both)
• Referral when these measures fail

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Migraine - Acute Rx

• Stepped care
• Simple oral analgesia (soluble form)
• Prokinetic anti-emetic
• Diclofenac and domperidone PR
• Triptians

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A proposal for the rational use of triptans

• Use Dose regimen
• Appropriate for first use of a triptan
  Sumatriptan 50 mg, zolmitriptan 2.5 mg,
  or almotriptan 12.5 mg orally
• When greater efficacy is needed Rizatriptan 10
  mg, sumatriptan 100 mg, or zolmitriptan 5
  mg orally, or sumatriptan 20 mg nasal spray
• In reserve (pending routine clinical experience)
  Eletriptan 40 - 80 mg orally
• When a rapid response is important above all
  Sumatriptan 6 mg subcutaneously
• When vomiting precludes oral therapy Sumatriptan
  6 mg subcutaneously
• When side effects are troublesome with
  Naratriptan 2.5mg or almotriptan
• other triptans 12.5mg orally
• When relapse is a particular problem Ergotamine
  1-2mg rectally
• It is assumed that each patient will try them
  in order until satisfied with the outcome.

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Migraine - Prophylaxis Rx

• Use (4-6months) when symptom control with best
  acute Rx is inadequate
• ß - Blockers without partial agonism (atenolol
  50-200 mg (unlicensed indication) or propranolol
  (long acting) 80-320 mg daily
• Sodium valproate 0.6-2.5 g daily (unlicensed
  indication)
• Pizotifen 1.5 mg daily
• Amitriptyline 50-150 mg at night (unlicensed
  indication)
• Methysergide 1-2 mg three times a day (hospital
  supervision recommended restrict use to less
  than six months)
• Mefanamic acid, oestrogen transdermal or COC in
  menstrually related migraine

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Tension-type Headache

• Attack-like episodes (usually 2-3 hours)
• Variable frequency
• Pressure tightness or band like
• Lacks specific feature
• Rarely disabling
• Chronic sub-type gt15 days per month
• May be stress related or assoc. with functional /
  structural cervical or cranial musculoskeletal
  abnormality (aet not mutually exclusive?)

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Tension-type Headache

• Address underlying factors (remember depression)
• Regular exercise
• Reassurance and OTC preparations (avoid codeine
  preps)
• Consider physiotherapy
• Amitriptyline (4-6 months)
• Sodium valproate

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Cluster headache

• Affects 11000 men and 16000 women
• Majority gt20yrs and many are smokers
• Episodic bouts (6-12weeks) once a year or every 2
  years around the same time
• Strictly unilateral around the eye,once or more
  daily, commonly at night
• Patient agitated and often beats head
• Eye red and watery and nose runs / blocked, /-
  ptosis
• Chronic form has a continuous milder background
  headache
• Usually persist more than 30 years

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Cluster headache

• May go undiagnosed for years
• Urgent specialist referral at each onset
• Alcohol is a trigger
• Acute Rx with sumatriptan or oxygen analgesics
  have no place!
• Prophylaxis options will depend on correct
  diagnosis
• Verapamil
• Prednisolone
• Lithium carbonate
• Ergotamine
• Methysergide

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Medication overuse headache

• Daily or near daily headache affects 5 pop and
  chronic overuse of headache preparations account
  50 of these
• Women men 51
• Common and probable key-factor is pre-emptive use
• Doesnt develop if taken for another indication
• Confirmed only when symptoms improve after
  medication is withdrawn
• Headache often oppressive and worse on
  awakening
• Increased with physical exertion
• Assoc. naus and vom rare

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Medication overuse headache

• Prevention and education
• Withdrawal suspected drugs
• Initial worsening of effects
• Usually improves within 2 weeks
• 50-75 revert to original headache type
• Relapse rate 40 within 5 years
• Most require extended support

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Links

• WWW.BASH.ORG.UK
• WWW.CLUSTERHEADACHES.ORG.UK
• WWW.HEADACHES.ORG
• WWW.DOCTORS.ORG.UK Clink on CME

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Questions?