Headache Management

A Guide for Doctors who do(with help from Practical Neurology Dec 2015 – Sinclair,

Sturrock,Davies, Matharu)

Dr Angus HickishFormerly of Burton and Bransgore Medical

Centres

Mr M Aged 53 Sudden onset very severe h/a during sex at

approach of orgasm. Vomited. Eventually got to sleep. H/a still present next morning although a bit better. Seen in practice that morning by a locum GP who referred him to neurology clinic (c&b). Partner heard about case and intervened; phoned consultant neurologist who arranged admission. Admitted to hospital 14 days later. CT brain normal. No LP. Reassured and discharged home. Attended c&b appointment 3 weeks later. Well no further episodes.

Mr P Aged 42 FH migraine. Occasional (rare) short lived

(20mins) episodes of visual disturbance effecting whole field of vision. Blurring – no positive features – usually when working on computer. Gets headaches with some alcoholic beverages. 5/52 ago had an episode of “usual” visual disturbance followed by headache which has persisted. Tried variety of OTC analgesics – no help. H/a intensity waxes wanes no discernable pattern. Photophobic when intense. Has become irritable. Convinced has brain tumour. Examination normal including discs.

MR C Aged 44 3 months recurring episodes of severe

peri/retro-orbital penetrating pain always on left. A least 1 episode per day. Some waken him at night when this occurs it is usually at a predictable time. Episodes last between 20 and 90 minutes. During the pain left eye reddens and waters profusely. Wanders around whimpering. Mr C is a police officer who is obliged to work shifts.

Mr H Aged 3810 years high headache burden. Periods of

daily headache lasting several months. Reckons last headache free day was 2 years ago. Tried a wide range of analgesia – nothing helps although some respite with Solpadeine presently needing to take 8 tablets per day to get by. Amitriptyline prescribed 1 year ago but did not get on with it. Recurrent headaches as a child. Has always had to avoid alcohol because causes headache. Twin sister has migraine.

Wants to be sorted out. In particular wants scan.

Mrs S Aged 67Migraine with visual aura during teens. Low

headache burden until mid 40’s then period (years) of high burden with periods of daily headache some very severe. Improved in late 50’s. Also tendency to headaches with orgasm since 20’s. From late 50’s rare h/a (apart from sex) but episodes of visual disturbance reminiscent of those as a teenager but not followed by h/a. (ziz-zag coloured effect appearing in right or left temporal field of vision enlarges migrates medially then fades – events last 25 mins.)

Mrs S Aged 67 – continued.2 months ago caravanning with husband in Lake District.

Decided to take a stroll before breakfast. Came across a sheep tangled in a wire fence. Able to release the animal after a bit of a tussle then developed exactly the same h/a as gets with sex. Went back to the caravan recalls entering the door but nothing for the next 2 hours. Husband in the van as entered he describes her as seeming very agitated and repeating over and over that she could not recall what she had been doing. Otherwise seemed very well and ate a hearty breakfast. After breakfast announced that she would like a shower. Took herself of to the ablutions block. Seemed calmer when she returned. Over the next few hours was able to start recalling some of the sequence of events but the period from arriving INSIDE the caravan until going for a shower remains blank.

Epidemiology

Worldwide prevalence 47%WHO listed cause of major disability3% of adults consult their GP with headache

each yearFemale to male ratio 3:1Accounts for 25% new referrals to neurology

clinicsCosts UK economy £2.25 billion annually

1. Migraine1.1 Migraine without aura1.2 Migraine with aura1.3 Ophthalmoplegic migraine1.4 Retinal migraine1.5 Childhood periodic syndromes that may be precursors to or associated with migraine1.6 Complications of migraine1.7 Migrainous disorder not fulfilling above criteria

2. Tension-type headache2.1 Episodic tension-type headache2.2 Chronic tension-type headache2.3 Tension-type headache not fulfilling above

criteria

3. Cluster headache and chronic paroxysmal hemicrania3.1 Cluster headache3.2 Chronic paroxysmal hemicrania3.3 Cluster headache-like disorder not fulfilling above criteria

4. Miscellaneous headaches not associated with structural lesion4.1 Idiopathic stabbing headache4.2 External compression headache4.3 Cold stimulus headache4.4 Benign cough headache4.5 Benign exertional headache4.6 Headache associated with sexual activity

5. Headache associated with head trauma5.1 Acute posttraumatic headache5.2 Chronic posttraumatic headache

6. Headache associate with vascular disorders6.1 Acute ischemic cerebrovascular disorder6.2 Intracranial hematoma6.3 Subarachnoid hemorrhage6.4 Unruptured vascular malformation6.5 Arteritis6.6 Carotid or vertebral artery pain6.7 Venous thrombosis6.8 Arterial hypertension6.9 Headache associated with other vascular disorder

7. Headache associated with nonvascular intracranial disorder7.1 High CSF pressure7.2 Low CSF pressure7.3 Intracranial infection7.4 Intracranial sarcoidosis and other noninfectious inflammatory diseases7.5 Headache related to intrathecal injections7.6 Intracranial neoplasm7.7 Headache associated with other intracranial disorder

8. Headache associated with substances or their withdrawal8.1 Headache induced by acute substance use or exposure8.2 Headache induced by chronic substance use or exposure8.3 Headache from substance withdrawal (acute use)8.4 Headache from substance withdrawal (chronic use)8.5 Headache associated with substances but with uncertain mechanism

9. Headache associated with noncephalic infection9.1 Viral infection9.2 Bacterial infection9.3 Headache related to other infection

10. Headache associated with metabolic disorder10.1 Hypoxia10.2 Hypercapnia10.3 Mixed hypoxia and hypercapnia10.4 Hypoglycemia10.5 Dialysis10.6 Headache related to other metabolic abnormality

11. Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose sinuses, teeth, mouth, or other facial or cranial structures11.1 Cranial bone11.2 Neck11.3 Eyes11.4 Ears11.5 Nose and sinuses11.6 Teeth, jaws, and related structures11.7 Temporomandibular joint disease

12. Cranial neuralgias, nerve trunk pain, and deafferentation pain12.1 Persistent (in contrast to tic-like) pain of cranial nerve origin12.2 Trigeminal neuralgia12.3 Glossopharyngeal neuralgia12.4 Nervous intermedius neuralgia12.5 Superior laryngeal neuralgia12.6 Occipital neuralgia12.7 Central causes of head and facial pain other than tic douloureux12.8 Facial pain not fulfilling criteria in groups 11 or 12

13. Headache not classifiable

International Headache Society Classification 1988

AEH Classification of Primary HeadacheMigraine Without aura With aura

Tension-type Headache Episodic Chronic

Cluster Headache and other trigeminal autonomic cephalalagiasCoital HeadacheExercise HeadacheCough HeadacheIce-pick Headache (Idiopathic Stabbing Headache) Hypnic Headache

Analgesic Headache

All Headache is Migraine…

Everybody gets Migraine…

Is the patient a migraineur?

Is the patient a migraineur?

Threshold?

IHS diagnostic criteriaMigraine without aura*An idiopathic recurring headache with: A.

At least 5 attacks fulfilling B-DB. Attacks last 4-72 hoursC. At least 2 of the following

- Unilateral location- Pulsating quality- Moderate or severe pain intensity- Aggravated by routine physical

activityD. At least one of the following during an attack

- Nausea and/or vomiting - Photophobia and phonophobia

E. Not attributed to another disorder* In children, attacks may be shorter; also more commonly bilateral and GI disturbance is more prominent

Worth Asking AboutBalance Disturbance Dysequilibrium Vertigo Motion sicknessAllodynia Including tendernessHyperosmiaAlcohol and headache

Is it a Tumour

Nausea/vomiting 50%“Classic” 17 BUT

> 3 months - unlikely>6 months – exceedingly unlikely

Red Flags New onset or change in headache in patients who are aged over 50 Thunderclap: rapid time to peak headache intensity (seconds to 5 mins) Focal neurological symptoms (eg limb weakness, aura <5 mins > 1 hr) Non-focal neurological symptoms (eg cognitive disturbance) � Change in headache frequency, characteristics or associated symptoms � Abnormal neurological examination � Headache that changes with posture � Headache wakening the patient up (NB migraine is the most frequent cause of

morning headache) � Headache precipitated by physical exertion or valsalva manoeuvre (eg coughing,

laughing, straining) Patients with risk factors for cerebral venous sinus thrombosis � Jaw claudication or visual disturbance � Neck stiffness � Fever � New onset headache in a patient with a history of human immunodeficiency virus

(HIV) infection New onset headache in a patient with a history of cancer

Treatment of Medication Overuse HeadacheWithdraw ? Cold turkey better that tapered.Indomethacin 50 tds or naproxen 250 tds

(+ppi) for 14 days?Diazepam 2mg tdsSteroidsStart neuro-modulator. Information. ( google Medication Overuse

Headache)

Some Nuggets Pregnancy 70% improve Triptans not licenced but NICE suggests consider GON block useful (? Also TCS) Avoid NSAID in last trimester (Reye’s syndrome)

Menstrual Migraine Pre-emptive Naproxen or frovatriptan.

“Status” Course of regular Naproxen 500 bd 3-4 weeks GON block Prednisolone