Headache (3.7)

Question 1

What are the types of headaches?

Answer 1

Primary headache

• Tension-type headache
• Migraine
• Cluster headache

Secondary headache

• Headache that is caused by associated condition or disease (minor or serious and life-threatening)

Question 2

What are the causes of secondary headaches?

Answer 2

Question 3

What are some red flags for headaches (SNOOPI)?

Answer 3

Question 4

What are some medications that commonly cause headache?

Answer 4

Question 5

What is a headache diary?

Answer 5

• Keeping a headache diary can help identify triggers for tension-type and migraine headaches
• Avoiding triggers (if possible) will not totally eliminate headaches but may reduce the frequency of headaches

Question 6

What is a tension-type headache?

Answer 6

Most common type of headache

• 9/10 people suffer from at least one tension headache per year
• More common in women than men
• Acute: less than 15 days in a month, no persistent Sx
• Chronic: more than 15 days per month, lasting more than 6 months

Triggered by:

• Stress, irregular or unhealthy meals, high caffeine intake, caffeine withdrawal, too much or too little sleep , problems related to menstrual cycle

Question 7

What are the symptoms of tension type headache?

Answer 7

• Bilateral pain, lasting 30 mins to 6 hours (can be longer)
• Pressure/tightness around the head
• Pain extends into the back of neck and shoulder
• Often in late afternoon or evening
• Non-throbbing in character (Dull aching)
• Mild to moderate intensity, not aggravated by routine physical activity
• Sx do not generally stop a person from getting on with their day-to-day activities
• Nausea and vomiting unusual

Question 8

How to teat infrequent tension-type headaches?

Answer 8

Paracetamol

• 1000mg (2 tablets of panadol 500mg paracetamol) orally q4h upto max 4g daily

Aspirin

• 600-900mg orally, repeat in 4 hrs prn, with food

Other NSAIDs

• Ibrupofen 200-400mg orally, repeat in 6 hrs prn
• Disclofenac 12.5-25mg orally, repeat in 6 hrs prn
• Naproxen sodium 275-550mg orally repeat in 6 hrs prn

Question 9

How to teat infrequent tension-type headaches (non-pharmacological)?

Answer 9

Amitriptyline 10 mg orally, at night, upto 75 mg daily

• Variation in effective dose
• To be continued for 3-6 months then reduce dose gradually

On prescription only –> require referral

Question 10

What about codeine for treatment of tension-type headache

Answer 10

• Paracetamol + codeine (OTC)
• Paracetamol + codeine + doxylamine (OTC)
• Aspirin + codeine (OTC)
• Ibruopfen + codeine (OTC)

Widely used but should be avoided in the tx of tension headache and migraine

> Can worsen symptoms of nausea and vomiting and impede the absorption of other drugs
>Will fail in 10% of population who do not metabolise codeine to morphine
>Closely associated with medication-overuse headache

Question 11

Who are those at risk of getting migraine headaches?

Answer 11

• Females 3x more likely
• Females worse during menstruation and improve during pregnancy
• Onset: adolescence or in the 20’s

Question 12

What are some migraine triggers

Answer 12

• Fluctuating hormone levels
• Cheese, red wine, cured meats, chocolate, food additives e.g. flavour enhancers
• Glare, flicker phenomena
• low BSL
• too much or too little sleep
• change in weather, some smells, high altitude
• stress

Question 13

What are some accumulation of triggers causing a migraine attack?

Answer 13

Question 14

What are the two types of migraines? What do both types of migraines share?

Answer 14

• Migraine without aura (common migraine)
• Migraine with aura (classical migraine)

Both types of migraines

• Prodromal phase: non-specific sx of irritability, anxiety, restlessness
• Headache (4-72 hours) –> unilateral first, may spread to opposite side, may swap side at next attack, severe throbbing pounding pain
• Nausea (90%), vomiting (30%)

Question 15

What are some properties of migraine without aura (common migraine)

Answer 15

Systemic symptoms during headache

• Anorexia, dizziness, chills, tremors, cold extremities, ataxia, dysarthria, difficulty in concentration

Postdromal phase

• headache pain wanes
• exhaustion, weakness, malaise
• possibility of recurrence of pain with sudden head movement

Question 16

What are some properties of migraine with aura (classical migraine)

Answer 16

• 20% of migraine sufferers
• Symptoms and duration similar to common migraine except for an aura
• Aura occurs between prodrome and headache

> evolves over 5-20 minutes and lasts less than 60 minutes

• Plenty of visual symptoms (positive and negative)

Question 17

How to manage migraines (pharmacological and non-pharmacological)

Answer 17

Pharmacological

• Abortive treatment
• Prophylaxis

Non-pharmacological

• rest/sleep in a quiet and dark room
• mental and physical inactivity
• keeping a diary to recognise and avoid triggers
• maintain fluid hydration if possible

Question 18

What are some abortive treatments for migraines?

Answer 18

• Simple analgesics are first line
• Use soluble formulations if possible (issue with impaired absorption due to gastric stasis)
• Use sufficient dosage

take early in the migraine attack

• before nausea and vomiting
• reduced gi motility which slows absorption

Question 19

When to use second line treatment for migraines? What is the second line treatment?

Answer 19

If first-line fails to manage the pain for three consecutive occasions, then move to the second line

TRIPTANS = second line

• Most effective when headache is beginning to develop

> not earlier e.g. during aura

> not later e.g. when headache becomes more severe

> relief within 30-60 mins

• no initial response - don not repeat
• may cause drowsiness –> patients should be warned

Question 20

What are some properties of triptans?

Answer 20

• 5HT₁ agonists

MOA: constrict cranial vessels by acting selectively at 5HT_1B/1D receptors. Also thought to inhibit the abnormal activation of trigeminal nociceptors

Indication: acute relief of migraine

CI: MI, hypertension

Caution: in those with risk factors for ischaemic heart disease (IHD) or at higher risk of CV adverse effects

Adverse effects

• Dependence may occur with overuse –> recurrent/rebound headaches and withdrawal
• Common a/e: sensations of tingling, heat, dizziness, drowsiness, nausea, vomiting, dry mouth
• Infrequent a/e: rash
• Rare: angina, MI, arrhythmias, stroke

Question 21

When sx of nausea at onset of headache, what to add with triptans?

Answer 21

• Metocloparamide 10-20mg orally
• Domperidone 20mg orally
• Prochlorperazine 5-10mg orally
• Combination of paracetamol and metoclopramide (500 + 5)

Severe migraine where nausea and vomiting prominent

• Prochlorperazine (rectal, IM, IV)
• Metoclopramide (IM/IV)

Question 22

What are some indications for the prevention of migraine?

Answer 22

• Two or more attacks/month that produce disability that lasts 3 or more days
• Lack of response, contraindication, or intolerance to symptomatic medications
• Use of acute migraine medication more than 2-3 times a week
• predictable pattern or regularity
• goal?

Question 23

How to prevent migraines (non-pharmacological)?

Answer 23

• Headache diary (monitor frequency, severity and triggers of attacks –> 4-6 weeks)
• LIfestyle changes (avoid trigger factors, reduction of caffeine, relaxation)
• Cognitive behavioural therapy (CBT)

Question 24

What drugs are used to prevent migraines (first line and second line)

Answer 24

See attached image

Prevention of migraine:

• Start low and tritrate upwards according to response
• It may take 1-3 months before full effect is seen
• If not effective after 1 month at max tolerated dose, withdraw and change to another one
• If headaches well controlled after 3-6 months, taper over 1-2 weeks to assess continuing need (diary useful)

Question 25

What is menstrual migraine?

Answer 25

* Severe throbbing pain * Acute treatment same as for migraine * Trigger: oestrogen withdrawal occuring on a regular basis between days -2 and +3 of the menstrual cycle * Different to the headache of PMS (-7 to -3) **Prevention - start 48 hours before expected onset of migraine** * Naproxen sodium 550mg orally bd, continue for 4-10 days * Mefenamic acid 500mg orally TDS, continue for 4-10 days * Oestradiol gel 1.5mg transdermally once daily for 7 days 3 days before menstruation

Question 26

What is a cluster headache?

Answer 26

Most severe of the primary headache disorders but uncommon (0.1%) \> more common in Caucasian males (x5-7 times) \> onset can occur at any age, most common in the late 20s \> occur in series lasting 2-12 weeks (i.e. cluster period) separated by painless periods lasting months or years **Triggers**: high altitude hypoxia, vasodilator tx, disturbances in rem sleep **Cause**: unclear, hypoxemia may play a role

Question 27

What are some symptoms of cluster headache?

Answer 27

* Rapid onset, severe pain lasting 15 mins to 3 hours * **Unilateral**, orbital, supraorbital, temporal, does not usually swap side * 1-8 attacks per day in the cluster period --\> typically same time each day * Attacks often occur nocturnally (50%) * GI Sx uncommon * Associated Sx on the same side that is affected

Question 28

How to treat cluster headaches? ## Footnote **REFER IF SUSPECTED CH**

Answer 28

**Acute therapy** * Inhalation of 100% oxygen at onset of headache * Sumatriptan 6mg S/C or 20mg intra-nasally **Preventative therapy** * Start promptly * Verapamil SR 240 mg daily (240-960mg in 1-4 doses) * Lithium and methysergide also used; not first line * May need a bridging treatment of prednisolone 50mg daily for 7-10 days (taper over 3 weeks, then stop) * Avoid alcohol during active cluster period

Question 29

What is medication overuse headache (1%)

Answer 29

Rebound headache, medicaiton abuse-headache * Prolonged and frequent use of all classes of acute medication for headaches * At risk patients \> frequent migraine or tension type headache \> increasing frequency and intensity of headaches (pattern of escalating use) \>chronic daily headache or chronic migraine * regular use of caffeine may contribute to perpetuating the headache into a chronic state **treatment** * withdrawal of overused agent; specialist care may be required * withdrawal symptoms last 2-10 days, complete resolution may take months. relapse common

Question 30

Self care for headaches

Answer 30

* Keep a headache dairy to identify pattern, possible triggers, helpful treatments and frequency of needing analgesics * Stress reduction --\> plan ahead and let others help you * learn and use relaxation techniques --\> massages and stretching exercises * healthy diet, limit high fat, sugar or salt diet * adequate fluid intake * limit caffeine intake * limit alcohol (No more than one standard drink per day) * exercise - at least 150 minutes eachw eek * plenty of rest and sleep * avoid smoking * pay attention to posture

Question 31

Summary for headaches?

Answer 31