What factors should you cover in the history of someone presenting with a headache ?
- Onset/ Peak - Acute Vs Sub-acute Vs Gradual
- Relieving features - Posture, headache behaviour
- Exacerbating - Posture, valsalva (sneezing, coughing, straining etc). Diurnal variation
- Associated features - Autonomic features (N+V), photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness etc
- Past medical history - Beware previous CA, predisposition to thrombosis
- Family history- particularly migraine
- Drug history - Headache diary may allow accurate account of OTC medication ingestion
- Social history
What are the red flags in someone presenting with a headache which warrants further investigation ?
- New onset headache >55
- Known/previous malignancy
- Immuno-suppressed
- Early morning headache
- Exacerbation by valsalva maneouver
What are the two main types of migraine ?
- Migraine with aura (20%)
- Migraine without aura (80%)
Who is migraines more common in and how often do people usually have migranes ?
Women 2.5:1
On average most have 1 attack per month
What is the diagnostic criteria for a mirgane without aura ?
Have to have had > or equal to 5 attacks
Attacks last 4-72 hours if untreated or unsuccessfully treated
Headache has at least two of the following characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Symptoms are aggravation by or causing avoidance of routine physical activity
During headache, at least one of the following
- Nausea and / or vomiting
- Photophobia (experience of discomfort or pain to the eyes due to light exposure) / Phonophobia (fear of loud sounds)
Headache not attributable to any other disorder
What is the diagnostic criteria for migraine with aura
At least 2 attacks fulfilling the following criteria
Aura consisting of at least one of the following, but no motor weakness:
- Fully reversible visual symptoms including positive features (e.g. flickering lights, spots or lines) and /or negative features (i.e. loss of vision)
- Fully reversible sensory symptoms including positive features (i.e. pins and needles) and / or negative features (i.e. numbness)
- Fully reversible dysphasic speech disturbance
Aura duration 20-60 minutes
Headache follows < 1 hours later but aura can occur simultaneously
Headache fulfilling criteria for Migraine without Aura begins during the aura or follows aura within 60 minutes (except occuring > or equal to 5 times as only needs to 2 times with aura)
Headache not attributed to another disorder
Describe the pathophysiology of migraine
- Stress triggers changes in the brain, these changes cause serotonin to be released
- Blood vessels constrict and dilate
- Chemicals including substance P irritate nerves and blood vessels causing pain.
What are the potential triggers for migraines ?
- Sleep
- Dietary - chocolate, cheese
- Stress
- Hormonal - Oral contraceptives
- Physical exertion
- Alcohol
- Lie-ins
What can be used to help identify triggers in someone presenting with migraines ?
Headache diary
What investigations are required in someone presenting with mirganes ?
For typical migraine no investigations are required
Consider imaging if:
- Late onset >55
- Known malignancy
- Acephalgic migraine - migraine aura without headache
What is a medication overuse headache ?
Also known as rebound headache usually occurs when analgesics are taken frequently to relieve headaches. Rebound headaches frequently occur daily, can be very painful and are a common cause of chronic daily headache.
Common causes are mixed analgesics (paracetamol + codeine/ opiates), ergotamine (ergot alkaloid) and triptans
medication overuse headache is a common reason for episodic headaches becoming daily, analgesia must be withdrawn and then limited
What is the lifestyle/ education adivce you should recommend to someone experiencing migraines ?
- Avoid triggers and eat a healthy balanced diet
- Ensure hydration taking in a min of 2L per day and decrease caffeine intake
- Decrease stressors
- Regular exercise
What is the treatment of acute migraines (i.e. one happening right now)?
- 1st line = NSAID (including aspirin) OR triptan OR both together
- 2nd line = paracetamol
- Consider adding an an antiemetic even in the absence of N&V but esp if they have N&V or gastroparesis e.g. metoclopramide or prochlorperazine
- NSAID - either aspirin, naproxen or ibuprofen
- Triptans include - 1st sumatriptan (try others if needed) rizatriptan, eletriptan, (clue is in the name for these ones)
When should you consider prophylactically treating someone with migraines ?
If they have >3 attacks per month or very severe disabiling symptoms
When prophylactically treating someone for migraines how long should a drug be trialled for to see if its working ?
A min of 4 months
Along with drug management what other treatments can you offer someone for prophylactic treatment of migraines ?
Non-phramacological management with acupuncture or relaxation exercises
What are the drug options for the prophylactic treatment of migraines ?
- 1st line options are - propanolol (B- blocker) or topiramate (propanolol preferred if women of child bearing age due to topiramates risk of teratogenicity)
- Amitriptyline sometimes considered
- 2nd line = course of acupuncture therapy
What are the contraindications to B-blockers ?
Contraindicated in asthma and PVD
What is the mechanism of action of topiramate and what are the side effects caused by it ?
Mechanism of action - it is a carbonic anhydrase inhibitor which acts on Na/Ca channels, inhibiting gultamate and enhancing GABA
SE - weight loss, parasethesia (pins & needles), impaired concentration & enzyme inducer
What are the side effects caused by amitriptyline ?
dry mouth, postural hypotension, sedation
What are some of the other options in the prophylactic treatment of migraines after the 1st line options ?
sodium valproate, riboflavin or a triptan (zolmitriptan or frovatriptan)
Very briefly what might make you think someone has sinusitis ?
Dull, constant ache over frontal or maxillary sinuses, with tenderness +/- post-nasal drip
Pain is worse on bending over
Very briefly what might make you think someone has GCA ?
- Older
- Has a headache that has lasted a few weeks
- Tender, thickened pulseless temporal arteries
- Jaw calduication
Very briefly what might make you think someone has acute glaucoma ?
- Typically in elderly long sighted people
- Constant aching pain develops rapidly around one eye radiating to the forehead
- Maredly reduced vision, haloes
- Nausea and vomiting
- Red congested eye
- Cloudy cornea
- Dilated non-responsive pupil
- Decreased visual acuity
