What causes a headache?
Structures:
- Trigeminovascular system
- Meninges
- CSF containing structures
- Muscles
- Nerves
Processes:
- ‘Neurogenic’ inflammation
- Inflammation
- Infection
- Pressure
- Obstruction
What is a primary headache?
No known underlying pathology
What is a secondary headache?
Potentially serious underling disease mechanism
What are the most consistent indicators of a secondary headache?
- Thunderclap (sudden onset)
- Associated focal neurological deficit
- Associated systemic features
- Patients > 50yrs
What is the hypothesised pathophysiology of a migraine?
- Cortical spreading depression (CSD) may be initiated by a slowly propagated wave of depolarisation in neurones and glial cells from the occipital pole.
- This is followed by a sustained suppression of spontaneous neuronal activity
- This suppression has been shown to occur alongside complex changes in brain blood flow, through alterations in vascular size
- CSD can activate the trigeminal nucleus caudalis (TNC), which is known to be associated with headache symptoms
What is an aura?
Transient neurological features which precede a headache or occur at headache onset
What kind of symptoms would an aura produce?
Visual
Sensory
What are the known triggers of a migraine?
- Foods containing tyramine
- Menstruation
- Relaxing after stress
- Flickering lights
- Jet lag
- OCP
CHOCOLATE
C - Chocolate H - Hangovers O - Orgasms C - Cheese O - OCP L - Lie-ins A - Alcohol T - Travel E - Exercise
What is an episodic TTH?
< 15 days per month
What is a chronic TTH?
≥ 15 days per month for > 3 months
What is an episodic migraine?
< 15 days per month
What is a chronic migraine?
≥ 15 days per month for > 3 months
What is an episodic cluster headache?
1 every other day to 8 per day with remission > 1 month
What is a chronic cluster headache?
1 every other day to 8 per day, with a continuous remission < 1 month in a 12-month period
What type of headache does medication overuse cause?
Migraine or TTH
What drugs cause a medication overuse headache?
- Triptans
- Opioids
- OCP
- Paracetamol
- Aspirin
- NSAIDs
What would you advise for a medication overuse headache?
- Restrict acute headache medications to no more than 2 days/week
- Encourage prophylactic treatments
- Stop triptan for 2-3 months
- Stop analgesic for 3 months
What is the management of a migraine with or without aura?
- Headache diary
- Triptan +/- NSAID/paracetamol (1st dose when HEADACHE STARTS, take 2nd if relapse)
Sumatriptan 100mg
If oral treatment for a migraine is not working, what wold you do?
- Non-oral triptan
Subcutaneous sumatriptan 6mg
Intranasal sumatriptan 10-20mg
- Non-oral Anti-emetic
Metoclopramide 10mg or prochlorperzine 10mgIf treatment for a migraine with or without aura is not working, what would you do?
Change triptan
When would you offer prophylactic treatment for a migraine with or without aura?
- QoL/business duties/ school attendance is severely affected
- 2 + attacks a month
- Migraine attacks do not response to acute drug treatment
- Frequent, very long or uncomfortable auras occur
What prophylactic treatment would you offer for a migraine with or without aura?
o Topiramate
o Propranolol
o Low-dose amitriptyline
What acute treatment would you offer for a TTH?
Oral paracetamol or aspirin
What prophylactic treatment would you offer for a TTH?
Amitriptyline
