16/02/2015

Question 0

How do you treat a tension headache?

Answer 0

Work out what triggers your headache. Go for a walk, some exercise, or simply take a break.
Massage may help. A hot flannel on your neck or a warm bath may also help.
Drink less caffeine and more water. Ear regularly, slow release energy foods, not lots of sugars.

Reduce the number of pillows. Sleeping on your side on high pillows means that your neck is bent which can cause tension and then headaches.

Get plenty of sleep and avoiding excessive noise.

You should not take painkillers for headache for more than a couple of days at a time. Also, on average, do not take them for more than two days in any week for headaches.

Take paracetamol, full dose as soon as a headache starts.

Opiate are not normally recommended for tension-type headaches. They are also the most likely type of painkiller to cause medication-induced headache if used regularly.

Question 1

Go through a surgical sieve for the causes of a headache

Answer 1

(VITAMIN D C AND E)

Vascular: migraine, TIA, stroke, venous sinus thrombosis (U), benign intracranial hypertension (U), hypertensive encephalopathy (U), pre-eclampsia (U)
Infective: meningitis, acute sinusitis
Idiopathic: cluster headaches
Iatrogenic: analgesia overuse headache, blood pressure lowering drugs, lumbar puncture, medication withdrawal (anti hypertensives, antihistamines, caffeine, opiates, corticosteroids),
Inherited:
Traumatic: head injury, concussive syndrome
Autoimmune: vasculitis
Metabolic: hypoglycaemia, dehydration
Inflammatory: encephalitis, temporal arteritis
Neurological: trigeminal neuralgia
Neoplastic: brain tumour (U), brain met, pituitary apoplexy (U)
Degenerative: cervical spondylosis
Congenital
Acquired: menstrual headache
Environmental: tension headache due to stress, carbon monoxide poisoning

Question 2

How do you treat migraine?

Answer 2

Mild to moderate migraine:
Step one:
Use soluble aspirin 600-900 mg (not in children) or ibuprofen 400-600 mg.
Avoid opiates.
Use prochlorperazine 3 mg buccal tablet if there is nausea/vomiting (not in paeds).
Consider combination preparations - eg, Paramax®.

Step two:
Diclofenac suppositories 100 mg with domperidone suppositories 30 mg if needed for vomiting.
Avoid if contra-indicated or unacceptable to the patient.

Moderate to severe headache:
Triptans (5HT1-receptor agonists) or ergotamine (not often used now due to side-effects such as nausea, vomiting and abdominal pain).
Eg. Sumatriptan.

For prophylaxis: beta blockers
Atenolol 25-100 mg bd is cardioselective, hydrophilic and has no intrinsic sympathomimetic activity, but is unlicensed. BASH suggests it is to be preferred over the other beta blockers, currently.

Question 3

How do you treat cluster headaches?

Answer 3

There is no likely prospect, at present, of curative medical treatment.

Prophylaxis should begin as soon as possible after the start of a new cluster period.
Failure of one drug does not predict failure of another.
Stop smoking, as this can increase the risk of chronic CH developing.
Abstain completely from alcohol during periods of CH and in chronic CH.
Maintain a regular sleep routine and good sleep hygiene (avoiding tea, coffee, etc).

Acute attack: Sumatriptan 6mg - by subcutaneous injection - and oxygen are likely to be the mainstay of treatment for most patients

Prophylaxis:
Verapamil is the first-line choice for both episodic and chronic CH.
It is started at doses of 40 mg twice-daily, building up to as much as 960 mg daily.
Side-effects of constipation and flushing may limit use in some.
ECG monitoring (for AV block) is required at doses over 120 mg daily

Prednisolone may be preferred, as unlike other treatments, it is started at full dose. A starting dose of 60-100 mg, once-daily for 2-5 days is recommended. If this treatment works it usually does so very quickly.
Treatment dose must be swiftly reduced after 2-5 days, in 10 mg increments every 2-3 days, so that treatment is discontinued in 2-3 weeks.

Question 4

How do you treat analgesia overuse headaches?

Answer 4

The most important part of treatment is to recognise and understand the cause of your frequent headaches - the painkillers or triptans. You can then devise a plan to stop the painkillers. It is best to plan a day to stop them altogether rather than try to cut down gradually. You should stop taking them for at least one month, and possibly two.

You must stop the painkillers or triptan completely to cure the problem. This is an uncomfortable process. You are likely to experience withdrawal symptoms - particularly an initial worsening of headache, but also some or all of:

Feeling sick (nausea).
Poor sleep.
Restlessness.
Tummy upset or diarrhoea.
Anxiety.

The headaches must resolve, or return to their original pattern, to have a confirmed diagnosis of medication overuse headache.