HEADACHES

PRIMARY CARE MANAGEMENT

Headaches-overview

 Primary headaches
 -Migraine
 -tension type
 -cluster headache/cephalgias
 -Others
Headache classification

 Secondary headaches-
 Trauma
 Cranial/ cervical vascular disorder
 Substance or its withdrawl
 Infection
 Homeostasis related
 Neck , sinuses,eyes,nose, teeth
 Anxiety/somatisation
Headache classification

 Neuralgias/other headaches
 Eg cranial neralgias, trigeminal neuralgia,
atypical facial pain
Headaches

 Affect 40% of UK population

 Migraine- 15% of population.
 Females:males 3:1
 Tension headaches- 80% of population
 Cluster headache 1 in 200
MIGRAINE
Migraine management

 Look at predisposing factors

 -stress,
fatigue,depression,anxiety,menstruation,
menopause, head/neck trauma.
 -trigger factors-dietary (20%), relaxation,
travel, missing meals/sleep, bright lights,
noise, strenuous exercise, mensruation.
Migraine

 Duration (hours3 days)

 Without aura in 2/3rd -unilateral, pulsating,
moderate/severe intensity, aggravated by
exercise, nausea/vomiting.
Photophonophobia
 With aura in 1/3rd- spreading scintillating
scotoma, unilateral paraesthesia, dysphasia
Migraine-drug intervention
Step one- simple analgesic+/- antiemetic
Eg aspirin 600-900mg +buccastem 3-6mgbd

Step two – rectal analgesic +/- antiemetic

Eg diclofenac suppositaries+domperidone
suppositaries
Step three – triptans-use at onset of pain, not
aura. Some rebound of symptoms in 20-50%
of patients within 48 hours.
Triptans

 Sumatriptan 50-100mg
 Zolmitriptan 2.5mg then rpt after 2 hours (not
children)
 Rizatriptan 10mg (equiv sumatriptan 100mg)
 Almotritan 12.5mg-HIGH EFFICACY. COST
EFFECTIVE
Migraine prophylaxis

 Ineffective for medication overuse headaches

 Use for 4-6 months-taper off over 2-3 weeks.
 Agents: betablockers, TCAD, pizotifen,
gabapentin, lisinopril
 Other agents-topiramate, sodium valproate,
clonidine
 Non drug therapies
Tension headache
Tension headaches

 Chronic tension type headache:-

-more than 15 days per month
- often daily
-often stress/lifestyle related
Tension headaches

 Episodic tension-type headache-

-may be unilateral but tend to be generalised
- pressure/tightness
- often spreads from neck
-stress related or related to cervical/cranial
musculoskeletal anomalies
Tension headache management

 Lifestyle changes
 Regular exercise
 Drug treatments-acute-aspirin 600-900mg,
ibuprofen 600mg, naproxen 250-500mg,
paracetamol 500mg-1g
 Prophylaxis-amitriptyline, nortriptyline,
propranolol, SSRIs
Medication overuse headaches

 Affects 1 in 50 adults
 Females:males 5:1
 First noted with phenacetin/ergotamine
 More common with aspirin/
NSAIDs/paracetamol/codeine/DF118
 Can take several weeks to resolve after
medication withdrawl
 Key feature-pre-emptive use of analgesia
Medication overuse headaches-cont.

 Low doses daily carry larger risk than higher

doses weekly
 Esp common if using simple analgesia more
days than not per month
 Using triptans, codeine >10days per month
 Worse on awakening in the morning
 Worse after physical exertion
Medication withdrawl headache-
treatment
 Stage one-abrupt withdrawl most effective-Sx
will worsen in days 3-7.
 Stage 2-recovery from MOH
 Stage 3- review and assess the underlying
primary headache disorder
 Stage 4- prevent relapse
 Failure to withdraw- naproxen
250mgtds/500mg bd, tcad.
References

 Mentor/GP notebook
 BASH (British Association for the Study of
Headaches)-guidelines. www.bash.org.uk
 Neurological Differential diagnoses. Batten,
J. 2nd edition.