301 Headache & Migraine Flashcards
What are the types of headache?
Non-migraine
Migraine
- Acute muscle contraction (tension), ‘ice-cream/ice-pick’, chronic daily, cluster, sinister
- Classical (with aura), common (without), children, associated with childhood travel sickness
What classes of drugs are common causes of headaches?
- Hormone meds (birth control, HRT)
- Erectile meds
- Caffeine (because of caffeine withdrawal)
- Heart & BP meds.
- Vitamins
What is a tension headache?
Most common cause of headache
Due to muscle spasm in neck/scalp
Caused by emotional stress (tension, anxiety, fatigue)
Pain is mild/moderate, non-throbbing, vice-like, tightness/squeezing/weight pressing on head
Usually both sides of head
Worsen through day, worse by stress
How does a migraine differ from a tension headache?
M: moderate/severe pain, unilateral, pulsating, aggravated by normal activity that patient has to stop
T: mild/moderate, bilateral, non-pulsating, not aggravated by normal activity
Management of a tension headache:
Pharmacological
Non-pharmacological
- OTC analgesic
- Relaxation, massage, hot bath
What headaches to we need to refer?
- “Ice cream”
- Chronic daily
- Cluster
- Sinister
“Ice cream” headache:
Pain
Duration
Trigger
- Severe, short & piercing, like “flash of lightening”, centred in one eye
- Seconds to minutes
- Eating cold food/drinks
Chronic daily headache:
Pain
Duration
Trigger
- Neck stiffness, migraine-type symptoms, vary by patient
- 4+ hours or >15 days a month
- Analgesic dependence
Cluster headache:
Pain
Duration
- Rare but 6-9x more common in men, unilateral excruciating pain, red eye, lacrimation, nasal congestion, rhinorrhoea, face swelling, miosis, droopy eye lid and oedema (mistaken for eye injury)
- Sudden - wake patient from sleep, intermittent - 8x a day, typically occurs same time daily, last 10 mins to 3 hrs
Cluster headache:
Management
- Rarely responds to analgesics
- Requires prophylactic treatment if attacks frequent or >3 weeks
- 100% O2 at 7-12L/min rate may abort attack
- Sumatriptan S/C
- High dose verapamil
What can sinister headaches indicate?
Meningitis, subarachnoid haemorrhage, temporal arteritis, trigeminal neuralgia, depression, glaucoma, raised intracranial pressure
Trigger points for referral in headaches
- Unresponsive to analgesics
- Children U12, with stiff neck or skin rash
- Occurs after recent (1-3 month) trauma or injury
- Lasted >2 weeks
- Accompanied by N + V but no other classical migraine symptoms
- Accompanied by neurological symptoms such as consciousness change
- New/severe in patient 50+
- Worsening symptoms
- Cluster symptoms
- Sudden/severe onset
Rash with headache
Tiny, red spots, do not go white when pressed
Urgent medical attention required
Death can occur within 2 hours of symptom onset
Warning symptoms of headaches:
Onset/severity
Frequency & duration
Accompanying symptoms
Pattern
Pain location
- Sudden, disabling, appears ill, meningococcal meningitis - child complain of cold hands, severe leg pain & pale skin
- Unremitting, worsening
- Loss of consciousness, rash, neck stiffness, altered vision
- Worsens on awakening
- Temporal location, above or lateral to eye
What is a migraine? And what are the symptoms?
- Episodic, patient well between attacks
- Prodrome, aura, headache & postdrome, headache, lateralised & pulsating, associated with N + V, phono/photophobia, trigger factors
Pathogenesis of migraine: prodromal phase
Activation of intracranial centre (hypothalamus, thalamus)
Explains irritability, food craving, mood swings, fatigue, stiff neck & phonophobia symptoms
Pathogenesis of migraine: aura phase
Cortical spreading depression
Pathogenesis of migraine: headache phase
Activation of trigemini-vascular system
Release of inflammatory markers: CGRP, substance P, VIP etc.
Pathogenesis of migraine: postdrome phase
Least studied phase could be result of continuation of brainstem activation
Associated genes with migraines:
Familial hemiplegic migraine
Migraine aura
Migraine chronification
Medication overuse headache
- CACNA1A, ATP1A2, SCN1A & PRRT2
- TRESK
- CALCA, RAMP1, NPTX2 & SH2D5
- COMT, GIT2, ZNF234 & SOCS1
Risk factors of migraines
- Trigger factors (keep diary)
- Foods (alcohol, caffeine, chocolate, diary products)
- Hormonal changes
- HRT, contraceptive pill, pregnancy
- Environmental
- Emotion, weather
- After stressful period
Migraine triggers: physiological & biochemical factors
- Deviated enzyme level
- Conc. of heavy metal level nitric oxide
- Mitochondrial enzyme dysfunction
- Disrupted neural networks in head
- Changes in ovarian hormone secretion
- Increased oxidative stress
- Metabolic derangements
- Monosodium glutamate
- Free iron deposition
- High insulin level
- Oestrogen level
Migraine triggers: genetics
- Polyglutamine repeats
- Frameshift variation
Migraine triggers:
Daily life patterns
- Weather changes
- Fasting and exhaustion
- Changes in sleep pattern
- Emotional stress
Migraine triggers:
food
- Chocolate
- Citrus fruits
- Fatty and fried food
- Sucralose, gluten
- Food colourings
- Tea, coffee
- Beverages containing caffeine
- Alcohol
- Diary products
Phases of migraines: prodrome (premonitory)
Heighten sensations, foreboding
Phases of migraines: aura
Fortification spectra, flashing lights, scotoma or paraesthesiae
Less common: speech difficulties
Phases of migraines: headache
Unilateral pulsatile, photophobia & phonophobia, N + V
Phases of migraines: postdrome
Headache - resolution, washed out
Symptoms of migraine: AUSTIN
Aggravated by activity
Unilateral location
Sensitivity to light & sound
Throbbing in nature
Intensity, moderate/severe
N + V present
Diagnosis of migraines (International Headache Society - IHS)
Repeated attacks of headaches lasting 4-72 hrs which have
2 of: unilateral pain, throbbing pain, aggravated by movement, moderate/severe intensity
1 of: N + V, phono/photophobia
Migraines differential diagnosis:
When to refer to GP
Central cause
Children
ADRs
- Headache 24+ hrs, eases as day progresses
- Effortless vomiting in morning, unsteadiness/clumsiness
- Children U12
- Suspected ADRs
Migraine management
Concordance paramount
Eliminate triggers
Acute intervention
Break-through attacks
Prophylaxis (high frequency >4 attacks/month)
How to manage migraine trigger factors:
Anxiety/emotion
Change of habits
Specific foods
Bright lights & noise
Strenuous exercise
- Relaxation/coping, yoga/meditation
- Revert to usual habits (is change true trigger?)
- Exclude for weeks trial (consult dietician)
- Avoid
- Avoid (physical exercise of benefit)
Current medicines for migraine treatment
- Meds to control pain
- Meds to abort/treat acute attack
- Products reducing N + V
- Meds reduce frequency of attacks
NICE guidance on:
Preventing migraines
- Galcanezumab (Inj)
- Fremanezumab (Inj)
- Erenumab (Inj)
- Rimegepant (Oral)
Migraine treatment: acute 1st line
- Offer simple analgesics
- Offer oral sumatriptan alone/with NSAID or paracetamol (if V restricts oral, consider zolmitriptan nasal spray or SC sumatriptan)
- Ibuprofen suitable NSAID, tolfenamic acid, naproxen & diclofenac
- If V restricts, consider non-oral NSAID, diclofenac suppositories (off-label)
Migraine treatment: acute monotherapy
If monotherapy preferred, offer oral triptan or NSAID, or aspirin (900mg every 4-6 hrs when necessary up to max. of 4g daily), or paracetamol
Migraine treatment: acute anti-emetic
- Consider anti-emetic (metoclopramide, domperidone or prochlorperazine) even in N + V absence
- Metoclopramide: not recommended >5 days
- Domperidone: not recommended >7 days (max. 10mg TDS) or <35kg weight
Migraine treatment: acute - triptans (POM) & P
C/I
Side effects
- 5HT1 agonists (specifically 1B & 1D)
Constrict blood vessels back to normal - IHD, uncontrolled high BP + 65+
- Tiredness & dizziness (common), heaviness on chest + throat
Examples of triptans
- Sumatriptan
- Almotriptan
- Eletriptan
- Frovatriptan
- Naratriptan
- Rizatriptan
- Zolmitriptan
OTC sumatriptan 50mg tablets
- Indicated 18-65 year olds
- Established pattern of migraine
- New migraines since 50 yrs: refer
- Wait 2 hours before 2nd dose
Migraines: acute - ergotamine
DO NOT USE
- 5HT1 partial agonist
- a-adrenoceptor, vasoconstrictor, trigeminal nerve
- Superseded by triptans
- Acute SEs: N + V, abdominal pains, leg cramps
- Overuse: ergotism
- Form of chronic daily headache
- Gangrene?
Medication overuse in headaches
- Taking meds too often for tension-type headaches/migraines
- 1 in 50 affected
- Pain oppressive, worse in morning
- Treat: stop current therapy, pain gets worse before better
- Patients at risk: using analgesics/triptans >15 days/month, refer requests for N4 Imigran/month
Preventing medication overuse headaches
Painkillers
- <15 days/month
- 3-4 doses over 1-2 days is OK
- Do not take consecutively for >2 days
- Avoid codeine containing products
Already used meds quota
- Cold turkey
- Speak to GP
Guide to migraine prophylaxis: 2 or 3 triptans tried unsuccessfully
- Start lowest dose
- Titrate up slowly
- Risk v benefit - Give adequate trial
- Stable
- Avoid interfering meds - Period of stability
- Taper or discontinue therapy
Migraine prophylaxis treatment options:
1st line
Topiramate
- Risk of foetal malformations & impair effectiveness of hormonal contraceptives
Propranolol
- Suitable for coexisting hypertension or anxiety, not suitable in asthma, COPD, peripheral vascular disease or uncontrolled HF
Migraine treatment: other prophylactic agents
Antidepressants
Anticonvulsants
OTC
Acupuncture
- Most discovered by chance
1. TCA (amitriptyline)
2. Valproate - prolonged/atypical migraine aura (no headache), not good for young women
3. Feverfew
Botox (Botulinum Toxin Type A)
- Non systemic meds is appealing
- Mechanism unknown
- Relaxes muscles - blocks pain feedback
- Repeated injections to head & neck
Migraines: monoclonal antibodies (Inj)
Galcanezumab, fremanezumab, erenumab
- All recommended as option for preventing migraine in adults only if:
They have 4+ migraine days/month
At least 3 preventative drug treatments have failed and company provides according to commercial arrangement
OTC sumatriptan:
supply criteria
- Migraine must be diagnosed by doctor/pharmacist
- Establish pattern of migraine (5+ migraine attacks over a year)
- Simple analgesics tried & ineffective
OTC sumatriptan: precautions for use
- Concomitant use
- SSRI/SNRI
- St. John’s Wort
- CoC
- Heart disease risk factors (C/I in patients with 3+ risk factors (diabetes, high cholesterol levels, smoking/NRT use))
OTC sumatriptan: counselling points
- Dose: 1 50mg tab taken ASAP after migraine started
- Swallow whole with water
- Single dose should relieve symptoms after 30 mins if symptoms not improved, no further doses taken for same migraine attack
- If 2nd migraine within 24 hrs, second dose may be taken
- Drowsiness may affect performance of skilled tasks (driving)
- Migraine diary may identify personal triggers
Sumatriptan: not to be used for
- Prevention of migraine
- Hemiplegic migraine
- Basilar migraine
- Ophthalmoplegic migraine
Sumatriptan C/I: hypersensitivity to
- Sulfonamides
- Sumatriptan
- Any excipients in preparation
Sumatriptan C/I: history of
- Seizures
- MI
- CVA/stroke
- Transient ischaemic attack (TIA/mini-stroke)
- CoC (if migraine recently started/symptoms got worse)
- Concomitant St. John’s Wort use
Sumatriptan C/I: other contraindications
- Hepatic/renal impairment
- Prophylactic use of sumatriptan
- Ischaemic heart disease
- Coronary vasospasm
- Cardiac arrythmia
- Peripheral vascular disease
- Hypertension
Sumatriptan C/I: interactions
- Ergotamine (& derivatives e.g. ethysergide)
- MAOIs
- 5HT1 receptor agonists (triptans)
- TCAs
- SSRIs/SNRIs
Sumatriptan C/I: patient characteristics
- Risk of heart disease.3+ CV risk factors
- U18s or 65+
- Pregnancy/breastfeeding
