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IPT 1 Lectures > Headache (3.7) > Flashcards

Headache (3.7) Flashcards

1
Q

What are the types of headaches?

A

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)
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2
Q

What are the causes of secondary headaches?

A
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3
Q

What are some red flags for headaches (SNOOPI)?

A
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4
Q

What are some medications that commonly cause headache?

A
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5
Q

What is a headache diary?

A
  • 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
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6
Q

What is a tension-type headache?

A

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
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7
Q

What are the symptoms of tension type headache?

A
  • 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
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8
Q

How to teat infrequent tension-type headaches?

A

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
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9
Q

How to teat infrequent tension-type headaches (non-pharmacological)?

A

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

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10
Q

What about codeine for treatment of tension-type headache

A
  • 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

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11
Q

Who are those at risk of getting migraine headaches?

A
  • Females 3x more likely
  • Females worse during menstruation and improve during pregnancy
  • Onset: adolescence or in the 20’s
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12
Q

What are some migraine triggers

A
  • 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
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13
Q

What are some accumulation of triggers causing a migraine attack?

A
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14
Q

What are the two types of migraines? What do both types of migraines share?

A
  • 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%)
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15
Q

What are some properties of migraine without aura (common migraine)

A

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
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16
Q

What are some properties of migraine with aura (classical migraine)

A
  • 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)
17
Q

How to manage migraines (pharmacological and non-pharmacological)

A

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
18
Q

What are some abortive treatments for migraines?

A
  • 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
19
Q

When to use second line treatment for migraines? What is the second line treatment?

A

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
20
Q

What are some properties of triptans?

A
  • 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
21
Q

When sx of nausea at onset of headache, what to add with triptans?

A
  • 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)
22
Q

What are some indications for the prevention of migraine?

A
  • 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?
23
Q

How to prevent migraines (non-pharmacological)?

A
  • 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)
24
Q

What drugs are used to prevent migraines (first line and second line)

A

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)
25
Q

What is menstrual migraine?

A
  • 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
26
Q

What is a cluster headache?

A

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

27
Q

What are some symptoms of cluster headache?

A
  • 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
28
Q

How to treat cluster headaches?

REFER IF SUSPECTED CH

A

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
29
Q

What is medication overuse headache (1%)

A

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
30
Q

Self care for headaches

A
  • 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
31
Q

Summary for headaches?

A

IPT 1 Lectures (24 decks)

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