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Top Ten Headache Tips
Dr David PB Watson
GPwSI Headache
Hamilton Medical Group
Aberdeen
Top Tip 1
• Diagnosis is by history, history and history
• T timing
• O other associated symptoms
• S site
• S severity
• I influences aggravating/relieving factors
• T type: what it feels like
Top Tip 2
• Secondary Headache is Rare
• Studies show PPV headache 0.09% in primary care for brain tumour i.e. 1 in 1000
• Migraine CT Scan 2 in 1000 abnormal
• Neurology OPD: 1 in 100 secondary cause
• A and E :1 in 10 secondary cause
“Red flags”
• Single cohort (Level 3) or expert opinion (Level 4)
• new onset headache in patients who are aged over 50 29-31
• abrupt onset (thunderclap) 28-30, 32, 33
• focal symptoms including atypical aura greater than one hour 28, 32, 34, 35
• abnormal neurological examination 28, 29, 35, 36
• altered mental status 28, 30, 34
• altered characteristics or associated features of headache 28, 31
• headache that changes with posture 37
• headache worse during physical activity, and the valsalva manoeuvre 28, 38
• patients with risk factors for thrombosis 34, 39, 40
• new onset headache in a patient with a history of HIV infection 41
• jaw claudication 16
• neck stiffness 30
• fever 42
• new onset headache in a patient with a history of cancer 9
Episodic primary headaches
Episodicprimary
headaches
Migraine +/- aura
Tension-type headache (TTH)
Cluster
Probablemigraine
Chronic cluster
Chronic migraine +/- medication overuseChronic tension
Chronic daily headache (CDH)
Hemicrania continuaNew daily persistent
Chronic primary headaches / chronic daily headaches
Top Tip 3
• Episodic disabling headache is migraine
• Over diagnosis of sinus headache and TTH
• 40% migraineurs miss ICHD-II criteria
What features make migraine more likely?
• episodic severe headache that causes disability11, 23, 24
• nausea16, 23
• sensitivity to light during migraine headache16, 23
• sensitivity to light between migraine attacks 25
• aura16, 18
• sensitivity to noise16
• exacerbation by physical activity16
• positive family history of migraine16
• The features which give the greatest sensitivity and specificity are Disability, Nausea and Sensitivity to light23
– ID Migraine validation study (Level 3)
Top Tip 4
• Choose acute migraine medication according to the patient’s symptoms
• Can use a step approach
Top Tip 5
• Response to triptans is idiosyncratic and consistency across attacks is variable
Top Tip 6
• A good response to migraine prophylaxis is a 50% response in 50% of patients
• Choice of prophylaxis is guided by co-morbidites
• Pizotifen is a poor drug
Top Tip 7
• Migraine with aura is an absolute contraindication to the combined contraceptive due to increased stroke risk
Top Tip 8
• All headache medications can cause headache
Top Tip 9
• There is no magic answer to the management of medication overuse headache other than to stop the medication
Top Tip 10
• Short lasting unilateral headaches with autonomic symptoms think of the trigeminal autonomic cephalalgias (TACs)
What features make TACs more likely?
• The following features differentiate trigeminal autonomic cephalalgias from migraine: 16, 26 (Level 4)
– Onset: rapid in TAC, gradual in migraine
– Duration: TACs < 3 hours, migraine 4 - 72 hours
– Frequency: multiple attacks may occur daily in TACs
– Restlessness during an attack: 100% in cluster headache, 50% in paroxysmal hemicrania
– Prominent ipsilateral autonomic features in TACs
Take home points
• migraine common• history is key to diagnosis• impact is important• remember overuse of medication• tailor treatment to patient• Refer if red flags, consider for chronic
migraine/MOH, TACs, untoward patient angst
Any Questions?
Case 1
• 22 years age
• Episodic headache for 5 years
• Attended for COP check
• What do you want to know?
Case 2
• 47 year old man
• 2 migraine headaches 6 and 10 years ago
• 3/12 ago had 3 weeks of headache awaking him from sleep
• What do you want to know?
Case 3
• 27 year old lady
• Migraine since 16
• Frequency is 1-2 per month
• Woke at 5 am with worst ever migraine
• What do you want to ask her?
Case 4
• 75 year old male
• migraine since 15, none for 10 years
• Last 3 days had migraine like headache
• Called GMEDs at 6 am as had D and V all night and still has headache
• What do you want to ask him?
Case 5
• 40 year old man severe headache for 1 hour
• Previous similar headaches diagnosed as migraine
• Not responded to naratriptan 2.5 mg
• What do you want to ask him?
Case 6
• 48 year old lady
• Migraine since 16, menstrually associated, none when pregnant
• Last 2 years more frequent
• Big headaches twice a month
• Little headaches 3 times a week
• What do you want to know?
Case 7
• 53 years, migraine since 15
• Last 6 years headache every day
• History of depression, agoraphobia, back pain
• Very noticeable profound parkinsonism tremor
• What do you want to know?
Abbreviated diagnostic checklist based on IHS 2004 criteria
Essential (3)
Essential (2)
Essential (1)
• Recurrent• No organic disease• Duration 4-72 h
• Moderate / severe + one other
• Recurrent• No organic disease• Duration 0.5 h-7 days
• Generalised• Pressure / tightness• Slight / moderate
• Photo / phonophobia
• Recurrent• No organic disease• Duration 4-72 h
• Unilateral• Pulsating• Moderate / severe• Aggravated by
movement
• Nausea / vomiting• Photo / phonophobia
Migraine Probable migraine Tension-type
Essential (3) = all items essential for diagnosis; Essential (2) = two items from list essential for diagnosis; Essential (1) = one item from list essential for diagnosis
IHS 2004
Time
Symptom intensity
The migraine attack
Prodrome Aura Headache Postdrome
Associated symptoms
Excitatory
Irritability
Elation
Hyperactivity
Yawning
Food cravings
Photophobia / phonophobia
Increased bowel / bladder activity
Inhibitory
Mental / physical slowing
Poor concentration
Word finding difficulty
Weakness / fatigue
Constipation / abdominal bloating
Anorexia
Chill
Prodrome• 60% of migraine sufferers experience
premonitory phenomena
Aura
• Affects 33% of migraine sufferers, but not in all attacks• Transient neurological symptoms resulting from cortical or brainstem
dysfunction• May involve visual, sensory or motor systems• Can occur before or during headache phase • Slow evolution of symptoms • Lasts for 20-60 minutes• Can be confused with transient ischaemic attack
Ferrari 1998Spierings 2003
Russell & Olesen 1996
Ferrari 1998Spierings 2003
Russell & Olesen 1996
Headache phase
• Throbbing or pounding quality• If left untreated, headache pain will progress to moderate /
severe intensity• Duration
– 4-72 hours in adults– 2-8 hours in children
• Exacerbated by movement*• One-sided temporo-orbital*• Abated by sleep*• Resolves spontaneously
*Usually*Usually
Postdrome
• Estimated to affect 90% of migraine sufferers• Phase after pain relief
– duration up to 24 hours• Sufferers may experience: hyperaesthesia, mood changes,
muscular weakness, fatigue, difficulty in concentrating• Extends period of migraine-related disability
Blau 1982
Migraine characteristics that aid diagnosis
Frequent association with menstrual cycle
Characteristic triggers
Paradoxical relationship to sleep
Familial history of migraine
Cognitive impairment with attacks
Dizziness and / or vertigo
Migraine triggers
Travel Fatigue Exercise Smoking Hunger Sleep Sex
DietaryHormonalSystemic
Externalstimuli
Physicalstresses
Emotionalstresses
Chocolate Cheese Alcohol Oral contraceptives Caffeine Menstruation Toothache
Anxiety Emotion Depression Shock Excitement Stress
ClimateHigh altitude
Hot bathsIntense smells Noise Glare
Thalamus
Nerve activation reducedPeptide release inhibited
PAIN
Directvasoconstriction
Nerve activation reducedPeptide release inhibitedDecreased pain
transmission
Higher CNS centresPAIN
Mode of action of triptans
PhotophobiaPhonophobia
Post-junctional receptor
Trigeminalganglion
Trigeminal nucleus
Caudalis
Autonomic activationNausea emesis
Post-junctional receptor
Post-junctional receptor
Vasodilationextravasation
NeuropeptidesNeurokinin ASubstance PCGRP
Trigeminal sensoryafferent nerve fibres
Ferrari & Saxena 1993Goadsby & Hoskin 1996
Ferrari & Saxena 1993Goadsby & Hoskin 1996
CNS, central nervous system CGRP, calcitonin gene-related peptide
Trigeminovascular system: Anti-migraine targets
Higher CNS Centres
PAIN
Thalamus
Autonomic activationNausea, Emesis
Trigeminal nucleus caudalis
Trigeminalganglion
Intracranialblood vessels
TARGET
TARGET
PhonophobiaPhotophobia
Cortex
The triptans
• Stronger than sumatriptan 100 mg Rizatriptan, eletriptan
• Equal to sumatriptan 100 mg almotriptan, zolmitriptan
• Weaker than sumatriptan 100mg, frovatriptan, naratriptan
Other primary headache
• Trigeminal autonomic cephalalgias (TACs)– Cluster headache– Paroxysmal Hemicrania (indometacin)– SUNCT
• Hemicrania continua (indometacin)
• New daily persistent headache
Cluster prophylaxis
• Prednisolone high dose (60 mg daily)
• Verapamil ( 240 to 720 mg daily)
• Lithium (600 to 900 mg daily)
• Methysergide( fibrosis retroperitoneum,pleural pericardial linings)
Cluster Acute Rx
• High flow oxygen (7 –12 l/ min)
• Sumatriptan subcutaneously
• Nasal zolmitriptan
• Lignocaine nose drops
• IV dihydroergotamine ( not UK)