Diagnosis and management of primary headaches-BASH guidelines

Aisha Bhaiyat14 June 2011

Aim to cover the following:

• Red flags• Migraines• Tension type headache• Cluster headaches• Medication overuse headaches

Classification of headaches

• Primary - migraines, TTH, cluster• Secondary – trauma, vascular, ICP (BIH or

tumour, substance or its withdrawal (CO, EtOH, medication), extracranial (acute glaucoma, sinusitis, teeth)

• Neuralgias - trigeminal

Red Flags

• New/unexpected headache in an individual• Thunderclap headache• Atypical aura (motor weakness or longer than 1 hour)• First aura on starting COCP• New onset headache in over 50’s or under 10’s• Persistent am headache with nausea• Progressive headaches• Postural headaches• New onset headache in those with PMH of cancer/HIV

Consider serious causes

• Intracranial tumours• SAH• Meningitis• Temporal arteritis• Primary angle closure glaucoma• Idiopathic intracranial hypertension• Carbon monoxide poisoning

History

• Timing-onset, frequency, duration, why present now

• Character-site, radiation, quality, intensity, associated symptoms

• Cause-prediposing/trigger, aggravating/relieving, FH

• Between attacks-well/residual/persisting symptoms. ICE

Migraine without aura-diagnosis

IHS criteria. At least 5 attack fulfilling the following:

• Duration- lasting 4-72 hours• Character, at least 2 of the following; unilateral,

pulsating, mod/severe, worse with physical activity

• Associations-nausea/vomiting or photophobia/phonophobia

• Not due to any other secondary cause

Migraine with aura-diagnosis

• Aura-progressive, last 5-60 minutes prior to headache. Hemianopic disturbance/spreading scintillating scotoma. Not blurring or spots. Can include other focal neuroligical symptoms eg parasthesia, dysphasia

• Consider TIA if new onset in elderly patients• Refer to specialist if aura includes motor

weakness, persists after resolution of headache or occur daily.

Scintillating scotoma

Tension type headaches-diagnosis

• Usually generalised, can be unilateral• Pressure/tightness around the head• Radiate from the neck• Lasts a few hours• No associated features

Cluster headaches-diagnosis

• M:F 6:1, over 20’s, smokers• Occurs same time each day, last 30-60 mins, 6-

12 wks, every 1-2 years, at the same time of year

• Intense, unilateral pain• Autonomic features: ipsilateral conjuntival

injection, lacrimation, rhinorrhoea, blocked nose and ptosis

Medication overuse headache-diagnosis

• Caffeine and codeine are prime causes. Although simple analgesia can be causes.

• Low doses daily is worse that high dose weekly. Detailed analgesia history.

• Headache sufferer for years, using analgesia.• Headache worse in the morning and with

physical activity.• Patient requesting stronger and stronger

analgesia

Physical examination

• BP-patient expectation, HT, migraine prophylaxis can cause HT

• Fundoscopy-papilloedema• Head and neck for muscle tenderness• CNS exam - Not specified in the guidelines• Investigations-only if a secondary cause

suspected

Migraine-management

• Aim is to control symptoms sufficiently to not impact on patients life ie cure unlikely.

• Trigger factor avoidance-eat reg, sleep• Drug treatment of acute symptoms• Prophylaxis

Migraine-acute Criteria for progressing to next step: Failure on 3

occassions• Step 1: po NSAID +/- po/buccal antiemtic• Step 2: pr NSAID +/- pr antiemetic• Step 3: antimigraine drugsIf step 3 fails-review diagnosis, compliance and how

medication is being used.• Step 4: Combine step 3 with step 1 or 2Do not use opiates-gastric stasis; risk of medication

overuse headache

Antimigraine drugs

Triptans• PO/Melts/Subcut• At the start of headache, whilst mild pain• Ineffective during aura• Can cause rebound migraine in 20-50% within 48 hoursErgotamine• Longer duration of action; Less likely to have rebound

migraine• More toxic and med overuse headaches

CI to step 3

• Uncontrolled HT• Risk factors for vascular disease• Age under 12 years

Migraine-prophylaxis

• Indication-frequent/inadequate control/triptan 10 or more days a month/analgesia 15 or more days a month/triptans or analgesia 2 or more days a wk

• Drugs should be titrated up slowly (avoid SE) and not deemed ineffective too early; trial should last 6-8/52

• Effective drug should be used for 4-6/12 and withdrawal tapered over 2-3/52

Migraine prophylax-1st line

• B-blockers-atenolol 25-100mg bd, CI asthma/CCF/PVD/depression

• Amitryptiline 10-150mg when migraine coexist with TTH, sleep probs, chronic pain, or depression

Migraine prophylaxis-2nd and 3rd line

• Topiramate (acute myopia/glaucoma) 25-50 mg bd

• Valproate 300-1000mg bd (FBC at starting, and LBP for 6/12)

• 3rd line: gabapentin, methysergide (risk of fibrosis), b-blocker + amitryptiline combined

Tension type headaches

• Reassurance• Ensure medication is not overused, risk of developing

medication overuse headaches.• Exercise + relaxation• NSAIDS, less than 2/7 per week• If frequent, break cycle by giving regular naproxen for

3/52, course not to be repeated• If chronic-Amitryptiline• Avoid opiates• Pain clinics

Cluster headaches

• Reassurance• Drugs + oxygen• Both symptomatic + prophylaxis required• Avoid EtOH and smoking

Cluster headaches-drugs

• Symptomatic: Sumitriptan 6mg s/c, oxygen 10-15l/min 10-20 mins

• Prophylaxis:Verapamil (ECG)/prednisalone 60-100mg od (2-5/7 and reduce by 10mg every 2-3/7)/ Lithium (serum monitoring)/methysergide (risk-fibrosis)/ergotamine

• Continue until headache free for 14 day (except steroids) and then gradually reduce.

Med overuse headaches

• Withdrawal• Recovery• Review the original headache disorder (which

may return after recovery from withdrawal) • Prevent relapse

Med overuse headaches

• All patients with headache should be educated about medication overuse

• Withdrawal-symptoms worsen, sick leave for 1-2 wks, good hydration.

• Ergot/triptan/non opioids stopped abruptly. Withdrawal headache last 2-10/7. May have nausea/vomiting/low BP/Hi HR/sleep probs/anxiety.

• Opioids slowly-consider referring to drug and etoh services.

• Withdrawal headache-reg naproxen for 3/52, course not to be repeated.

Summary

• Consider serious causes incl CO poisoning• Remember to check BP and fundoscopy• Avoid prescribing opioids• Advice re lifestyle and risks of med overuse• If occurring frequently, consider regular naproxen

for 3/52 to break cycle or prophylaxis treatment• Consider chronic pain management options• Further information www.bash.org.uk