Difference between primary and secondary headaches?
primary: caused by chemical activities in the brain, nerves, blood vessels surrounding the skull or muscles of the back or neck.
secondary: often due to an underlying cause such as an injury from a car accident.
Possible causes of headaches?
exposures: dehydration, CO
infection: acute sinusitis, ear infection
brain-related: blood clot, brain tumour
other conditions: glaucoma, hypertension
four different types of headaches
sinus: pain usually around forehead and cheekbones. Can be accompanied with stuffy nose and worsening pain bending forward or lying down.
cluster: severe pain around eye - can be red and patients are unable to lie down - can pace around to relieve pain
tension headache: tightness or pressure across forehead (dull pain), no nausea or vomiting
migraine: throbbing pain generally limited to one half. Accompanied with nausea and vomiting as well as sensitivity to light and sound
Triggers for referral of a headache
- over 50 (first episode) or sudden onset
- onset after trauma
- increase infrequency over weeks and months
- signs of systemic illness (fever, rash, neck stiffness)
- new onset in immuncomp patient, HIV or cancer.
Difference between episodic and chronic TTH
episodic: infrequent <1 day/ month
or frequent: 1-4 days/ month
chronic: > 15 days/ month
Pathophysiology of TTH
peripheral: increased pain sensitivity around the head and neck (altered nociception)
central: increased excitability of CNS and decreased decreased body’s natural inhibition of pain
non-pharm tx for TTH
- CBT
- relaxation training
- biofeedback
- headpad on neck and shoulders
- acupuncture ≥ 6 sessions
pharmacological tx for TTH
- paracetamol
- aspirin
- NSAIDs
pharmacological prophylaxis for TTH
amitriptyline or nortriptyline for 8 weeks. If effective, continue for another 6 weeks and then withdraw. If ineffective try mirtazapine or venlafaxine for 8-12 weeks and consider referral to specialist.
Migraine criteria
Severe intermittent headache, ≥ 2 of following features:
Pain affecting one side of the head
Pulsating/throbbing pain
Aggravated by exertion
Nausea ± vomiting
Sensitivity to light and sound
Aura: vision changes, flashes of light, blind spots, zig zag lines, etc.
what are the four phases of a migraine
- prodromal phase- occurs hours or days before the headache (prophylaxis here) – high levels of 5HT –> vasoconstriction, impaired bloodflow
- aura: immediately precedes the headache
- headache (acute treatment here) – low 5HT –> protective intracranial vasodilation
- postdrome: effects experienced following the end of a migraine attack (inability to concentrate, fatigue, depressed mood, lack of comprehension) – widespread vasoconstriction mediated by alpha2- adrenoceptor
Acute Non-pharmacological Approaches for migraine
- Cold packs over the forehead or back of skull (supraorbital and greater occipital nerves)
- Hot packs over the neck and shoulders (innervation of scalp)
- Neck stretches and self-mobilisation
- Rest in a quiet dark room
Acute pharmacological Approaches for migraine
non-opioid analgesic: paracetamol, aspirin, another NSAID; ibuprofen
antiemetic (if nausea present): metoclopramide, domperidone, ondansetron
triptans: eletriptan, sumitriptan, naratriptan
Pharmacology of Triptans
MOA: agonist, act selectively at 5HT1B/1D receptors.
Inhibit the abnormal activation of trigeminal nociceptors:
- Constriction of cranial vessels, ↓ cerebral blood flow
- Inhibition of peripheral nociceptors
- Inhibit pain transmission in CNS
precautions of triptans
Cerebrovascular/ Cardiovascular disease: C/I in uncontrolled HT and peripheral vascular disease,
coronary vascular disease, transient ischaemic attack
Elderly: potential increased risk of cardiovascular effects
Pregnancy/Breastfeeding: avoid if possible but sumatriptan is agent of choice if needed
Migraine Prophylaxis
Only reduce frequency and severity of attacks; treatment for acute attacks still required.
- 2 or 3 severe migraine attacks each month, significantly impaired QOL:
acute migraine treatment > 2-4 days/ month
If the first drug is not effective after a reasonable trial (ie maximum tolerated dose for at least 8 to 12 weeks), try another but if multiple not working, refer
example tx: amitriptyline, nortripyline, candesartan, propranolol, verapamil, topirimate, sodium valproate,
Supplements and Migraines
3-month trial of supplementation (harm is low). Supplementation can be used in combination.
- magnesium, riboflavin (Vit B2), CoQ10
