Headache (3.7) Flashcards
What are the types of headaches?
Primary headache
- Tension-type headache
- Migraine
- Cluster headache
Secondary headache
- Headache that is caused by associated condition or disease (minor or serious and life-threatening)
What are the causes of secondary headaches?
What are some red flags for headaches (SNOOPI)?
What are some medications that commonly cause headache?
What is a headache diary?
- Keeping a headache diary can help identify triggers for tension-type and migraine headaches
- Avoiding triggers (if possible) will not totally eliminate headaches but may reduce the frequency of headaches
What is a tension-type headache?
Most common type of headache
- 9/10 people suffer from at least one tension headache per year
- More common in women than men
- Acute: less than 15 days in a month, no persistent Sx
- Chronic: more than 15 days per month, lasting more than 6 months
Triggered by:
- Stress, irregular or unhealthy meals, high caffeine intake, caffeine withdrawal, too much or too little sleep , problems related to menstrual cycle
What are the symptoms of tension type headache?
- Bilateral pain, lasting 30 mins to 6 hours (can be longer)
- Pressure/tightness around the head
- Pain extends into the back of neck and shoulder
- Often in late afternoon or evening
- Non-throbbing in character (Dull aching)
- Mild to moderate intensity, not aggravated by routine physical activity
- Sx do not generally stop a person from getting on with their day-to-day activities
- Nausea and vomiting unusual
How to teat infrequent tension-type headaches?
Paracetamol
- 1000mg (2 tablets of panadol 500mg paracetamol) orally q4h upto max 4g daily
Aspirin
- 600-900mg orally, repeat in 4 hrs prn, with food
Other NSAIDs
- Ibrupofen 200-400mg orally, repeat in 6 hrs prn
- Disclofenac 12.5-25mg orally, repeat in 6 hrs prn
- Naproxen sodium 275-550mg orally repeat in 6 hrs prn
How to teat infrequent tension-type headaches (non-pharmacological)?
Amitriptyline 10 mg orally, at night, upto 75 mg daily
- Variation in effective dose
- To be continued for 3-6 months then reduce dose gradually
On prescription only –> require referral
What about codeine for treatment of tension-type headache
- Paracetamol + codeine (OTC)
- Paracetamol + codeine + doxylamine (OTC)
- Aspirin + codeine (OTC)
- Ibruopfen + codeine (OTC)
Widely used but should be avoided in the tx of tension headache and migraine
> Can worsen symptoms of nausea and vomiting and impede the absorption of other drugs
>Will fail in 10% of population who do not metabolise codeine to morphine
>Closely associated with medication-overuse headache
Who are those at risk of getting migraine headaches?
- Females 3x more likely
- Females worse during menstruation and improve during pregnancy
- Onset: adolescence or in the 20’s
What are some migraine triggers
- Fluctuating hormone levels
- Cheese, red wine, cured meats, chocolate, food additives e.g. flavour enhancers
- Glare, flicker phenomena
- low BSL
- too much or too little sleep
- change in weather, some smells, high altitude
- stress
What are some accumulation of triggers causing a migraine attack?
What are the two types of migraines? What do both types of migraines share?
- Migraine without aura (common migraine)
- Migraine with aura (classical migraine)
Both types of migraines
- Prodromal phase: non-specific sx of irritability, anxiety, restlessness
- Headache (4-72 hours) –> unilateral first, may spread to opposite side, may swap side at next attack, severe throbbing pounding pain
- Nausea (90%), vomiting (30%)
What are some properties of migraine without aura (common migraine)
Systemic symptoms during headache
- Anorexia, dizziness, chills, tremors, cold extremities, ataxia, dysarthria, difficulty in concentration
Postdromal phase
- headache pain wanes
- exhaustion, weakness, malaise
- possibility of recurrence of pain with sudden head movement
What are some properties of migraine with aura (classical migraine)
- 20% of migraine sufferers
- Symptoms and duration similar to common migraine except for an aura
- Aura occurs between prodrome and headache
> evolves over 5-20 minutes and lasts less than 60 minutes
- Plenty of visual symptoms (positive and negative)
How to manage migraines (pharmacological and non-pharmacological)
Pharmacological
- Abortive treatment
- Prophylaxis
Non-pharmacological
- rest/sleep in a quiet and dark room
- mental and physical inactivity
- keeping a diary to recognise and avoid triggers
- maintain fluid hydration if possible
What are some abortive treatments for migraines?
- Simple analgesics are first line
- Use soluble formulations if possible (issue with impaired absorption due to gastric stasis)
- Use sufficient dosage
take early in the migraine attack
- before nausea and vomiting
- reduced gi motility which slows absorption
When to use second line treatment for migraines? What is the second line treatment?
If first-line fails to manage the pain for three consecutive occasions, then move to the second line
TRIPTANS = second line
- Most effective when headache is beginning to develop
> not earlier e.g. during aura
> not later e.g. when headache becomes more severe
> relief within 30-60 mins
- no initial response - don not repeat
- may cause drowsiness –> patients should be warned
What are some properties of triptans?
- 5HT1 agonists
MOA: constrict cranial vessels by acting selectively at 5HT1B/1D receptors. Also thought to inhibit the abnormal activation of trigeminal nociceptors
Indication: acute relief of migraine
CI: MI, hypertension
Caution: in those with risk factors for ischaemic heart disease (IHD) or at higher risk of CV adverse effects
Adverse effects
- Dependence may occur with overuse –> recurrent/rebound headaches and withdrawal
- Common a/e: sensations of tingling, heat, dizziness, drowsiness, nausea, vomiting, dry mouth
- Infrequent a/e: rash
- Rare: angina, MI, arrhythmias, stroke
When sx of nausea at onset of headache, what to add with triptans?
- Metocloparamide 10-20mg orally
- Domperidone 20mg orally
- Prochlorperazine 5-10mg orally
- Combination of paracetamol and metoclopramide (500 + 5)
Severe migraine where nausea and vomiting prominent
- Prochlorperazine (rectal, IM, IV)
- Metoclopramide (IM/IV)
What are some indications for the prevention of migraine?
- Two or more attacks/month that produce disability that lasts 3 or more days
- Lack of response, contraindication, or intolerance to symptomatic medications
- Use of acute migraine medication more than 2-3 times a week
- predictable pattern or regularity
- goal?
How to prevent migraines (non-pharmacological)?
- Headache diary (monitor frequency, severity and triggers of attacks –> 4-6 weeks)
- LIfestyle changes (avoid trigger factors, reduction of caffeine, relaxation)
- Cognitive behavioural therapy (CBT)
What drugs are used to prevent migraines (first line and second line)
See attached image
Prevention of migraine:
- Start low and tritrate upwards according to response
- It may take 1-3 months before full effect is seen
- If not effective after 1 month at max tolerated dose, withdraw and change to another one
- If headaches well controlled after 3-6 months, taper over 1-2 weeks to assess continuing need (diary useful)
What is menstrual migraine?
- Severe throbbing pain
- Acute treatment same as for migraine
- Trigger: oestrogen withdrawal occuring on a regular basis between days -2 and +3 of the menstrual cycle
- Different to the headache of PMS (-7 to -3)
Prevention - start 48 hours before expected onset of migraine
- Naproxen sodium 550mg orally bd, continue for 4-10 days
- Mefenamic acid 500mg orally TDS, continue for 4-10 days
- Oestradiol gel 1.5mg transdermally once daily for 7 days 3 days before menstruation
What is a cluster headache?
Most severe of the primary headache disorders but uncommon (0.1%)
> more common in Caucasian males (x5-7 times)
> onset can occur at any age, most common in the late 20s
> occur in series lasting 2-12 weeks (i.e. cluster period) separated by painless periods lasting months or years
Triggers: high altitude hypoxia, vasodilator tx, disturbances in rem sleep
Cause: unclear, hypoxemia may play a role
What are some symptoms of cluster headache?
- Rapid onset, severe pain lasting 15 mins to 3 hours
- Unilateral, orbital, supraorbital, temporal, does not usually swap side
- 1-8 attacks per day in the cluster period –> typically same time each day
- Attacks often occur nocturnally (50%)
- GI Sx uncommon
- Associated Sx on the same side that is affected
How to treat cluster headaches?
REFER IF SUSPECTED CH
Acute therapy
- Inhalation of 100% oxygen at onset of headache
- Sumatriptan 6mg S/C or 20mg intra-nasally
Preventative therapy
- Start promptly
- Verapamil SR 240 mg daily (240-960mg in 1-4 doses)
- Lithium and methysergide also used; not first line
- May need a bridging treatment of prednisolone 50mg daily for 7-10 days (taper over 3 weeks, then stop)
- Avoid alcohol during active cluster period
What is medication overuse headache (1%)
Rebound headache, medicaiton abuse-headache
- Prolonged and frequent use of all classes of acute medication for headaches
- At risk patients
> frequent migraine or tension type headache
> increasing frequency and intensity of headaches (pattern of escalating use)
>chronic daily headache or chronic migraine
- regular use of caffeine may contribute to perpetuating the headache into a chronic state
treatment
- withdrawal of overused agent; specialist care may be required
- withdrawal symptoms last 2-10 days, complete resolution may take months. relapse common
Self care for headaches
- Keep a headache dairy to identify pattern, possible triggers, helpful treatments and frequency of needing analgesics
- Stress reduction –> plan ahead and let others help you
- learn and use relaxation techniques –> massages and stretching exercises
- healthy diet, limit high fat, sugar or salt diet
- adequate fluid intake
- limit caffeine intake
- limit alcohol (No more than one standard drink per day)
- exercise - at least 150 minutes eachw eek
- plenty of rest and sleep
- avoid smoking
- pay attention to posture
Summary for headaches?
