Headache

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Headache
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HEADACHES

• PRIMARY CARE MANAGEMENT

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Headaches-overview

• Primary headaches
• -Migraine
• -tension type
• -cluster headache/cephalgias
• -Others

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Headache classification

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

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Headache classification

• Neuralgias/other headaches
• Eg cranial neralgias, trigeminal neuralgia,
  atypical facial pain

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Headaches

• Affect 40 of UK population
• Migraine- 15 of population.
• Femalesmales 31
• Tension headaches- 80 of population
• Cluster headache 1 in 200

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MIGRAINE
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Migraine
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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.

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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

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Migraine-drug intervention

• Step one- simple analgesic/- antiemetic
• Eg aspirin 600-900mg buccastem 3-6mgbd
• Step two rectal analgesic /- antiemetic
• Eg diclofenac suppositariesdomperidone
  suppositaries
• Step three triptans-use at onset of pain, not
  aura. Some rebound of symptoms in 20-50 of
  patients within 48 hours.

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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

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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

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Tension headache
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Tension headaches

• Chronic tension type headache-
• -more than 15 days per month
• - often daily
• -often stress/lifestyle related

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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

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Tension headache management

• Lifestyle changes
• Regular exercise
• Drug treatments-acute-aspirin 600-900mg,
  ibuprofen 600mg, naproxen 250-500mg, paracetamol
  500mg-1g
• Prophylaxis-amitriptyline, nortriptyline,
  propranolol, SSRIs

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Medication overuse headaches

• Affects 1 in 50 adults
• Femalesmales 51
• First noted with phenacetin/ergotamine
• More common with aspirin/ NSAIDs/paracetamol/codei
  ne/DF118
• Can take several weeks to resolve after
  medication withdrawl
• Key feature-pre-emptive use of analgesia

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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 gt10days per month
• Worse on awakening in the morning
• Worse after physical exertion

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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.

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References

• Mentor/GP notebook
• BASH (British Association for the Study of
  Headaches)-guidelines. www.bash.org.uk
• Neurological Differential diagnoses. Batten, J.
  2nd edition.