Headaches and migraines Flashcards
What are the different types of headaches?
Tension-type
Cluster headache
Migraine
Miscellaneous
Describe a tension headache.
This it the most common type and is thought to be due to muscle spasms in the neck/scalp.
- Can be caused by emotional stress- tension, anxiety, tiredness
Pain:
- mild to moderate
- Non-throbbing, vice-like- tightening or squeezing
- Usually both sides of head
- may worsen throughout the day or by stress
Describe a cluster headache.
These are rare- but 6-9x more common in men.
Pain:
- Excruciating pain, severe unilateral pain
- Often around nose, eyes- can also cause lacrimation, red eye, nasal congestion, runny nose, facial sweating, miosis, droopy eyelids- may be mistaken for an eye injury
- Duration: sudden onset- may wake up from sleep.
- Also intermittent onset- can occur up to 8x a day
- lasts between 10mins to 3 hours
- need to rule out meningitis, bleeds, and cranial arterisis
Differential diagnosis for meningitis: fever, dislike of bright light, N+V, rash, neck stiffness
Differential diagnosis for CA/bleed: head trauma, loss of consciousness, jaw pain on side of face
What differential diagnoses must be rule out in a suspected cluster headache?
- need to rule out meningitis, bleeds, and cranial arterisis
Differential diagnosis for meningitis: fever, dislike of bright light, N+V, non-blanching rash (glass test), neck stiffness. Ask if patient can put their chin onto their chest.
Differential diagnosis for CA/bleed: head trauma, loss of consciousness, jaw pain on side of face
Discuss the use of the pain ladder in headaches.
Pain score 1 - mild pain:
- Paracetamol 1g (4-6 hourly) (max 8 tabs per day)
Pain score 2- mod pain:
- Paracetamol 1g (4-6 hourly) (max 8 tabs per day)- this stays throughout the ladder
+ codeine (weak opioid)- 30-60mg 4-6 hourly (As POM, OTC dose doesn’t reach evidence based dose)
+ Plus Ibuprofen 400mg 6-8 hourly (Or other NSAID- where not Cid)
Pain score 3: severe pain:
- Paracetamol 1g (4-6 hourly) (max 8 tabs per day)
+ Appropriate opioid e.g. morphine, fentanyl, oxycodone- slow titration
+ Plus Ibuprofen 400mg 6-8 hourly (Or other NSAID- where not Cid)
For breakthrough pain: 1/6th of the main opioid daily dose e.g. if have 40mg per day, may give 6-7mg as a breakthrough PRN dose as an oramorph liquid
How do you give breakthrough pain relief?
For breakthrough pain: 1/6th of the main opioid daily dose e.g. if have 40mg per day, may give 6-7mg as a breakthrough PRN dose as an oramorph liquid
Describe a migraine?
- Episodic
- Symptoms- prodrome (sensations before), aura, headache, postdrome
Headache: - Unilateral- usually once side
- Pulsatile, throbbing pain
- Associated with N+V, photophobia
What gender is more likely to have migraines?
migraines are 3x more likely in women
What age group is common for migraines?
Onset peaks at 5-6 years old, but a lot go into remission after childhood.
Then there is another peak around 25
This gradually drops off- very rare to experience first migraine at age of 50-55+
What are the different types of migraines?
CLASSICAL:
- Migraine with aura- preceded by focal neurological disturbance (nerves in part of brain not firing properly) e.g if in visual centre- see zigzags, blurry spots
Only about 15% HAVE AN AURA
COMMON:
- Migraine without aura
ABDOMINAL MIGRAINE:
- Childhood migraine in about 3-10% of school children.
Often associated with gi symptoms e.g. nausea, cramps, loss of appetite.
May withdraw from play, not like noises
What is the pathophysiology being migraines and the different theories?
There are more theories than an exact known MOA.
- There is a genetic link- chromosomal defects from 10 possible polymorphisms that impair calcium channels- involve serotonin release
- Is a trigger threshold
- Vasoconstriction and vasodilation by Wolf:
Vascular constriction across the head/brain = Aura
Dilation = headache
This theory was disproved as the headache actually begins before dilation occurs. - Brain hypothesis:
That there is a cortisol spread of depression due to an increase in extracellular K+ cones and a decrease in blood flow = which leads to neuronal inhibition. - Sensory nerve hypothesis:
Trigeminal nerve that goes to the meninges is fired which increases inflammatory mediators e.g. cytokines, prostaglandins etc = pain
None of these explain the initiation of a migraine
Seratonin- see an increase in seratonin metabolites in urine during a migraine attack = blood concs of serotonin decreases.
If injected with serotonin, it can relieve a migraine
Thalamus and hypothalamus:
these are the emotional centres of the brain that regulate sleep, temp, hormonal activity etc
if start changing sleep cycle and diet = this is detected by the thalamus and hypothalamus causing the firing of nerves to GIT= N+V, to the trigeminal nerve = inflammatory mediators and to the brain = corticol spreading of depression, aura, pain
Describe the trigger threshold in migraines
Ask patient to keep a headache diary to identify triggers:
Food- caffeine, chocolate, alcohol, dairy
Hormonal changes- HRT, contraceptive pill, pregnancy
Environmental- emotion, weather
Migraines are often a result of changes in standard routines e.g. significant life event
Has a points system
e.g.
if a patient was stressed = 1 point
Walked past a strong petrol smell = 1 point
Had an alcoholic drink = 1 point
This alcohol at the end of the day, may have pushed them over the trigger threshold = migraine
What are the phases of a typical migraine?
- Prodrome- before the migraine, may have heigtened sensations, sense of foreboding, cravings
- Aura- fortification spectra e.g. zig-zag lines, flashing lights, scotoma (spots in vision), pins and needles
- Headache- unilateral, pulsatile, throbbing pain. Also may have photophobia, photophobia, N+V, speech difficulties
- Postdrome- wash out phase= tired, worn out
How are migraines diagnosed?
International headache Society criteria:
- Repeated attacks of headaches lasting 4-72 hours which has the at least 2 of the following features:
Unilateral pain
throbbing pain
Aggrevated by movement
Moderate-severe intensity- impacting daily function
And at least one of:
N+V
photophobia/phonophobia
5 attacks meet criteria for official diagnosis
When would you refer a headache to the GP?
- Not easing over after 24 hours
- Headache that eases as the day progresses especially with effortless morning vomitting- can be a central cause e.g. cancerous growth squashing the CTZ at night when laying down = pressure, but is relieved in the morning.
- Children with unsteadiness on feet
- Children under 12 where paracetamol is not happening
- Suspected ADRs of drug e.g. GTN, CCBs,
What is the acute management of migraines?
- Use of headache diary to assess the support needed
- Elimination/management of trigger factors
- Acute intervention- pain relief
- Prophylaxis- if high frequency or severity
Acute- simple analgesics:
- If can recognise pre-symptoms, take before headache starts
- Dispesible and effervescent forms may be preferred as they have more rapid absorption and absorption may be impaired in N+V
e.g. Paracetamol or NSAIDA
Aspirin-900mg
Ibuprofen- 400mg
Paracetamol- 1g
- Migraleive- contains pink and yellow tablets
P= paracetamol, codeine, buclizine (anti-histamine)
Y = paracetamol and codeine
BNF states this is not effective- don’t prescribe
Buccastem M- 3mg buccal prochlorperazine which acts on CTZ- good if also have N+V
Triptans (POM) e.g. Sumitriptan 50-100mg.
These are 5ht-1 agonists that act predominantly at 5HT-1B & D in the head and cranial area- constrict blood vessels back to normal = rebound dilation
- these are Cid in IHD, uncontrolled HTN, over 65s
- Take these drugs when you know the headache is a migraine (take just analgesia until sure).
- If take triptan and migraine disappeared but then reappears, can take another dose after 2 hours. If take and nothing happens, there is no point taking another dose.
Where are the triptans contra-indicated?
IHD, uncontrolled HTN, over 65s
What are possible side effects of the triptans?
Tiredness
dizziness
heaviness in chest and throat- need to counsel to the patient that this is not a CV event
What is an important counselling point for the triptans?
Can cause heaviness in chest and throat- need to counsel to the patient that this is not a CV event
What are the formulations available for the different triptans and what are their + and -?
Sumatriptan:
- ve = poorly orally absorbed
+ve = SC acts fast
+ ve = nasal formulations act fast-licenced under 18 years
Zolmitriptan:
+ve: available as an orange flavour melt (sumitriptan tastes bad)
When can and can’t you take another dose of a triptan?
If take triptan and migraine disappeared but then reappears, can take another dose after 2 hours. If take and nothing happens, there is no point taking another dose.
What are medication overuse headaches?
Taking medication too often for headaches or migraines can lead to medication overuse headaches, where the medication itself is responsible for worsening. This is because the body gets so used to the medicine it wants it all the time.
How do you treat and prevent medicine overuse headaches?
Treat:
Stop current therapies, then look at the management
Prevent:
Use of painkillers:
- Mac of 15 days/month
- 3-4 doses over 1-2 days is ok
- don’t take consecutively for >2days
- Avoid codeine-containing products
What patients are at risk of medicine overuse headaches?
Those using analgesics/triptans for >15 days per month
When are prophylactic treatments in migraines indicated?
- when level of functional impairment caused by the migraine affects daily life
- Headaches >2 per week
- Amount of acute meds used and how they are using them
- Patient compliance- will they comply with daily dosing, side effects, risks
- Success/failure of previous therapy
What are the prophylactic treamtment options for migraines?
1st line:
Beta-blockers, specifically Propranolol
- Need to ensure compatible if patient already on other meds
- Weight up Session- fatigue, bronchoconstriction, cold extremities
Not commonly used:
Pizotifen- 5HT2 antagonist
Weak effectiveness so not used often
SEs- weight gain sedation
Methysergide- 5HT2 antagonist
SE: N+V, Fibrotic conditions
More commonly used:
TCAs e.g. Amitriptyline
Anti-convulsants e.g. valproate, topiramate
- These are good but caution in young women- need good contraception. Also risk of hirtsuism
