Transcript OH and Headache Oct 2005

Top Ten Headache Tips
Dr David PB Watson
GPwSI Headache
Hamilton Medical Group
Aberdeen
Top Tip 1
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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”
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Single cohort (Level 3) or expert opinion (Level 4)
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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
Cluster
Migraine +/aura
Episodic
primary
headaches
Probable
migraine
Tension-type
headache (TTH)
Chronic primary headaches /
chronic daily headaches
New daily persistent
Hemicrania continua
Chronic daily
headache (CDH)
Chronic migraine +/medication overuse
Chronic tension
Chronic cluster
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?
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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 comorbidites
• 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)
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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
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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
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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
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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
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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
Migraine
Probable migraine
Tension-type
• Recurrent
• Recurrent
Essential (3) • Recurrent
• No organic disease • No organic disease • No organic disease
• Duration 4-72 h
• Duration 4-72 h
• Duration 0.5 h-7 days
Essential (2) •
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Unilateral
Pulsating
Moderate / severe
Aggravated by
movement
• Moderate / severe
+ one other
Essential (1) • Nausea / vomiting
• Photo / phonophobia
• Generalised
• Pressure / tightness
• Slight / moderate
• Photo / phonophobia
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
The migraine attack
Symptom
intensity
Associated
symptoms
Prodrome
Aura
Headache
Time
Postdrome
Prodrome
• 60% of migraine sufferers experience
premonitory phenomena
Excitatory
Inhibitory
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Irritability
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Mental / physical slowing
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Elation
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Poor concentration
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Hyperactivity
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Word finding difficulty
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Yawning
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Weakness / fatigue
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Food cravings
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Photophobia /
phonophobia
Constipation / abdominal
bloating
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Anorexia
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Chill
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Increased bowel / bladder
activity
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 1998
Spierings 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
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Exacerbated by movement*
One-sided temporo-orbital*
Abated by sleep*
Resolves spontaneously
*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
Climate
High altitude
Hot baths
Intense smells
Noise
External
Glare
stimuli
Travel
Fatigue
Physical
Exercise
stresses
Smoking
Hunger
Sleep
Sex
Chocolate
Cheese
Alcohol
Oral contraceptives
Caffeine
Dietary
Menstruation
Hormonal
Toothache
Systemic
Emotional
stresses
Anxiety
Emotion
Depression
Shock
Excitement
Stress
Mode of action of triptans
Trigeminal sensory
afferent nerve fibres
Photophobia
Phonophobia
PAIN
Neuropeptides
Neurokinin A
Substance P
CGRP
Vasodilation
extravasation
Post-junctional
receptor
Postjunctional
receptor
Higher CNS
centres
Thalamus
Trigeminal
ganglion
Direct
vasoconstriction
Nerve activation
reduced
Nerve
activation
reduced
Peptide release
inhibited
Peptide
release
inhibited
Decreased pain
transmission
Postjunctional
receptor
Trigeminal nucleus
Caudalis
Autonomic activation
Nausea emesis
CNS, central nervous system
CGRP, calcitonin gene-related peptide
Ferrari & Saxena 1993
Goadsby & Hoskin 1996
Trigeminovascular system: Anti-migraine targets
Cortex
Higher
CNS Centres
PAIN
Phonophobia
Photophobia
Thalamus
TARGET
Trigeminal
ganglion
Autonomic activation
Nausea, Emesis
Trigeminal
nucleus caudalis
TARGET
Intracranial
blood vessels
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
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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
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High flow oxygen (7 –12 l/ min)
Sumatriptan subcutaneously
Nasal zolmitriptan
Lignocaine nose drops
IV dihydroergotamine ( not UK)