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)