Migraine/Headaches

Question 1

Migraine/Headache:

Approach to Diagnosis?

Answer 1

Headache

Red flags symptoms?

SNOOP4
Systemic symptoms
Neurological signs
Onset sudden/Orthostatic/first or worse
Older than 50yo
P1 pattern change
P2 precipitated by valsalvea
P3 postural aggregation
P4 papilloedema, pulsatile tinnitus

• unilateral temple
• peripartum
• when straining/coughing/exertion/orgasm/preorgasm
• visual changes, neck stiffness, photophobia

Blue flags (explanation of cause is suggested)
- occipital pain
- whiplash history
- eye strain
- vasodilator use
- medication over use

**Medication overuse headache/migraine:
Use of analgesics, opioids, or triptans on ≥10 days/month
or
paracetamol/NSAIDs on ≥15 days/month

Green flags (>/= 2/3 = migraine)
-disability associated
-nausea
-photosensitive

Consider seizures and normal pressure hydrocephalus as a cause

Define symptoms
a) Location of pain/symptoms
- Face/Jaw/Temple (GCA, TMJ, dental cause, sinusitis, paroxsymal hemicrania, trigeminal cephalgia, stabbing headaches (1st trigeminal division intermittent pain and no autonomic features)
- Ears (otitis externa, otitis media, Ramsey Hunt Syndrome/VZV)
- Eyes/peri-orbital (Acute - closed angle glaucoma, preseptal/post septal orbital cellulitis, cluster migraine, Herpes Zoster ophthalmicus/VZV) (Chronic - cluster migraine, Short lasting headache with Unilateral Neuralgiform Conjunctival Tearing (SUNCT))

b) frequency/duration
1) <15/30 days or >15/30 days/month
2) <4hrs duration or > 4hrs duration

5) Sub-diagnosis is based on symptomatology

<4hrs duration

• Cluster headaches
• Trigeminal cephalgia
• Paroxysmal hemicrania
• Stabbing headaches (1st trigeminal division intermittent pain no autonomic features)
• Hypnic headaches (occur in the elderly, wake them from sleep, no autonomic features)
• cough/exercise/sex/thunder clap headache
• nummular (small localised superfical pain ‘epicrania’ = NSAIDs, TCA, gabapentin, botox)

> 4hrs duration

• Migraine (sensory aura 25% of the time)
• Tension headache
• Hemicrania continua
• New daily persistent headache (continuous from onset, moderate pain, variable intensity, can change location)

Hybrid headaches
-triggers of associated issues tend to worsen migraine
treat associated conditions for best benefit
-neck, TMJ, sinus issues

Triggers:
*use a headache diary
-stress
-sleep disturbances
-alcohol/caffeine
-weather changes (likely overestimated)
-menses
-dietary factors (fasting, dehydration, highly processed foots, artificial additives)

Question 2

Migraine/Headache:

Approach treatment?

Answer 2

Medication over use management:

• review coping strategies being used
• address any underlying psychological barriers
• slow (4 - 6 weeks) or abrupt cessation (then 5 - 10 days acute management) of medications implicated
• slow if withdrawal with things like opioids, benzodiazepines)
• the symptoms will temporarily get worse before they get better
• short term prophylaxis through change over (use a different class then original medication of issue)
• best evidence for onabotulinum toxin A (3 monthly) and topiramate
• short course steroids also useful
• aim is to initiate different prophylaxis and that there should be limited use of acute medications

Migraine management:

At onset of migraine take
1) paracetamol 1g/ibuprofen 400mg/aspirin 900mg/diclofenac 50mg/naproxen 500mg
AND
Anti-nausea medication

Wait 45 - 60min

2) IF symptoms not reducing then take
- eletriptan 40 to 80 mg orally. If symptoms recur, wait at least 2 hours before repeating the dose (maximum dose 160 mg in 24 hours)

• All triptans on PBS except long scripts of naratriptan
• better tolerated are eletriptan and naratriptan but can also have lower level of effect
• sumatriptan is the only one available intranasal

**Menstrual migraine
-take triptan 2 days before until 3 days
after bleeding starts

3) trial simple prophylaxis agents (try all 3 but not together)
a) Magnesium (elemental) 400 to 650 mg orally, once daily for 3 months, then review
OR
b) Riboflavin (Vitamin B2) 200 mg orally, twice daily for 3 months, then review
OR
c) Ubidecarenone (Coenzyme Q10) 150 to 300 mg orally, once daily for 3 months, then review.

4) Prophylaxis
- numerous options
- ai is to try and use one that will assist with other comorbidity also to reduce polypharmacy burden if possible

Avoid opiates/gabapentanoids due to dependence risk

Options:
amitriptyline 10 mg
candesartan 4 mg 	
nortriptyline 10 mg
pizotifen 0.5 mg 	
propranolol 20 mg 	
sodium valproate 200 mg	
topiramate 25 mg 	
verapamil sustained-release 90 mg

Cluster headache:
1) Sumatriptan 6mg subcutaneously (most effective)
2) oxygen therapy 15lL/min for 15min
3) greater occipital nerve blocks for prophylaxis
4) Other prophylactic agents include Verapamil, topiramate, sodium valproate, gabapentin, high dose melatonin, lithium
(specialist input required)

Safest is verapamil in the correct patients - aim is too up titrate when predictable attacks will occur and downtitrate in between. Initiation involves:

• prednisolone 50mg for 5 days then reduce by 10mg every 2 days
• simultaneously initiating verapamil at start of steroid therapy

Hemicrania continua and paroxysmal hemicrania:
-One of the diagnostic criteria for both conditions is a 100% response to indomethacin

Indomethacin 25mg daily, uptitrating by 25mg every 3 days

• if reach 75mg daily with no response then wean off
• if responsive wean to lowest effective dose - will be lifelong with PPI coverage ideally