W21 Headache and Migraine Flashcards
What are headaches categorised into?
- Categorised by International Classification of Headache Disorders (ICHD)
-
Primary Headaches – not associated with underlying condition (most common)
Migraine, Tension headache, cluster headache - Secondary Headaches – Caused by underlying issue/condition
- Trauma/injury to head/neck area, intracranial haemorrhage, giant cell arteritis, stroke/TIA, brain malignancy
- Substance exposure, misuse/overuse, withdrawal
- Infection, glaucoma, psych. disorders, HTN
Examples of primary headaches? (3)
-
Primary Headaches – not associated with underlying condition (most common)
Migraine, Tension headache, cluster headache
Examples of causs of secondary headaches? (3)
- Secondary Headaches – Caused by underlying issue/condition
- Trauma/injury to head/neck area, intracranial haemorrhage, giant cell arteritis, stroke/TIA, brain malignancy
- Substance exposure, misuse/overuse, withdrawal
- Infection, glaucoma, psych. disorders, HTN
How can you assess a headache?
- Identify RED FLAGS that suggest a serious secondary cause – for further specialist assessment
- Pain – Onset, duration, frequency, pattern, location, severity, quality
- Associated symptoms – Aura, N&V, motion problems, photophobia, phonophobia
- Autonomic symptoms – Lacrimation, conjunctival injection, rhinorrhoea
- Precipitated or associated with a trigger?
- Comorbidity present?
- Medication taken for symptom relief?
- Symptoms relieved?
- Impact on daily activity/QoL?
- Examination – Vital signs, mental state, alertness, neck/face/intracranial structure, Neuro exam, fundoscopy
- Headache diary – Useful if primary diagnosis unclear but secondary cause ruled out – period of 8 weeks
What is a Migraine?
with aura?
- Common Primary headache disorder
- Episodes of Moderate/Severe headache – unilateral mostly, pulsating or throbbing
- Associated with photophobia, phonophobia, N&V
Aura
-Sensation experienced before or during a migraine attack
-Visual aura – Blind spot, blurred vision, zigzag lines
-Sensory aura – Pins & needles
2 types of migraine?
What are the triggers? (6)
- Episodic – attacks occur less than 15 days/month
- Chronic – attacks on at least 15 days per month for more than 3 months
Triggers:
Factors that can start an attack
Poor sleep
Irregular/missed meals
Excess caffeine
Menstruation
Stress
What are the factors increasing risk of chronic migraine?
- High frequency of episodic migraine
- Overuse of medication to treat acute episodes
- Excess caffeine
- Obesity
- Snoring/sleep disorders
- Co-morbidity – head injury, pain disorder, anxiety, depression
- Life events – divorce, marriage, job loss
Prevalence and Prognosis of migraine
(for info)
Prevalence;
1 in 7 sufferers globally
2-3 times more common in women
Most common in age 25-55years
Around 8% of migraine sufferers have chronic migraine
Prognosis;
Improves with age
Improves after menopause in women
Pregnancy improvement – reduced frequency or severity of attacks in trimesters 2&3
Migraine without Aura Diagnosis:
At least 5 attacks of:
Headache lasting 4-72hours in Adults (2072hrs in adolescents)
Headache with at least 2 of:
Unilateral location, pulsating/throbbing/banging, moderate or sever pain, aggravated by or affects daily activities
Headache with nausea & vomiting, photophobia and phonophobia
Headache not accounted for by another diagnosis
Migraine with aura diagnosis:
What are the conditions?
2 attacks of..?
3 of?
At least 2 attacks of:
1+ fully reversible aura sympom – Visual, sensory or speech
At least 3 of:
1+ aura symptom spreading over 5 mins
2+ aura symptoms in succession
Each aura symptom lasts 5-60 mins
At least one symptom is unilateral
At least one symptom is positive
Headache not accounted for by another diagnosis
Atypical aura:
What are the non-regular aura symptoms? (5)
Motor weakness
Double vision
Visual symptoms in one eye only
Poor balance
Reduced consciousness
Admission or urgent specialist advice needed
Aura with no headache:
- Attack of aura but without headache
- No headache makes it difficult to exclude other causes
- Further investigation needed
What are
Prodromal symptoms?
Postdromal symptoms?
Menstrual related migraine?
Symptoms occur from 2 days up to hours before other migraine symptoms
-Fatigue, poor concentration, neck stiffness, yawning
Occur AFTER headache and can last up to 48 hours
-Fatigue, elation, depressed mood
Women or girls with migraine symptoms around the start of menstruation cycle for at least 2/3 cycles
What is the differential diagnosis of Migraine?
Tension Headache
Cluster Headache
Paroxysmal Hemicrania
Cough/cold Headache
Trauma/injury to head/neck
Intracerebral Haemorrhage
Central Venous Thrombosis
Giant Cell Arteritis
TIA/Stroke
Idiopathic Intracranial Hypertension
Neoplasm
Substance Withdrawal
Medication Overuse
CO Exposure
Intracranial Infection
Hypoxia
Hypertension
Pre-eclampsia/Eclampsia
Closed Angle Glaucoma
Dental Problem
Otitis Media
Sinusitis
Somatisation Disorder
Management of Migraine in Adults?
Advice/Self Care
Migraine Diary
Avoid Triggers
Lifestyle changes – Stress, sleep hygiene, hydration, regular meals, exercise, weight
Treat co-morbidities – Sleep apnoea, insomnia, depression & anxiety
Medication Overuse Headache (MOH)
- Restrict acute meds use to max. 2 days a week
Inc. risk if using simple analgesics >15 days/month or Triptans/combination analgesics for >10 days/month
Combined Hormonal Contraceptives – CI in women with migraine + aura
Acute treatment of migraine? (3)
When to follow up?
- Simple analgesics ( NSAIDs, Aspirin, Paracetamol)
- Triptans(Sumatriptan, Naratriptan, Rizatriptan, Zolmitriptan)
- Anti-emetics (Prochloperazine, Metoclopramide)
- Acute medication should be started as early as possible at onset of pain or aura
- No ergots or opioids should be used
- Follow up in 2-8 weeks
Migraines-
When to follow up?
- 2-8 weeks after starting treatment – sooner if headache changes or experiencing adverse effects of Tx
- Assess frequency of attacks, Tx effectiveness, adverse effects, lifestyle improvement
Ctu Tx if effective, appropriate use and well tolerated
If Tx ineffective:
- Reconfirm diagnosis – Referral???
- Alternative Triptan or combine with an NSAID or Paracetamol
- Consider prophylactic therapy
Refer to specialist if migraine is of uncommon type
Prophylactic Treatment of migraines:
What is the aim of treatment?
What are the treatment options?
Aim to reduce frequency, severity and duration of attacks & avoid MOH
When to consider:
- Attacks are impacting on QoL and daily activities
- Acute Tx is CI or ineffective
- Patient is at risk of MOH – rule out before starting, also manage suspected MOH with drug withdrawal
Treatment options:
Propranolol
Topiramate
Amitriptyline
Pizotifen
(DO NOT offer Gabapentin)
Non Pharm – Behavioural intervention, Acupuncture, Riboflavin
Prophylactic Treatment
Consider CI, co-morbidities, risk of adverse effects
Discuss benefits and risks with patient
Topiramate - Teratogenic
discuss risk of foetal malformation
reduced effectiveness of hormonal contraceptives
importance of effective contraception
Initiate low dose and titrate according to efficacy and tolerability
Advise patient on rationale for prophylaxis and lifestyle advice
Follow up every 2-3 weeks to assess effectiveness, adverse effects and titrate dose
Advise on keeping headache diary, review sooner if anything changes, can take up to 8 weeks to notice any improvement
6-12 months after starting consider need to continue and gradually withdraw treatment
Management of Migraine in 12-17 year olds:
- What to ask in hx taking?
- What meds to give? treatment?
History, examination, assessment:
* Causes/triggers
* Time off school/college
* General health
* Anxiety/concern?
* Headache diary
Management:
* Self care – avoid triggers, keep headache diary
* Simple analgesia for symptomatic relief – Paracetamol, Ibuprofen
* Nasal Triptan therapy if simple analgesia not effective – oral triptans not licensed in under 18s
* Follow up in 1 month
* Refer to sec. care if prophylactic treatment needed – should not be started in primary care
Management of Migraine in Pregnancy & Breastfeeding
- Migraine may improve in trimester 2 and 3 of pregnancy
- Try non – pharm measures first – avoi triggers, relaxation, CBT
- Many treatments CI or limited evidence of safety
- Awareness of risks if drug therapy needed
- Paracetamol 1st line
- Ibuprofen or Triptan if ineffective (Sumatriptan preferred triptan)
- Avoid NSAID in trimester 3
- NO Aspirin or opiates
- Follow up in1 month – low threshold for sec. care referral
- Seek specialist advice if prophylactic treatment needed
Triptans
What is their receptor target? MoA?
Examples?
First-line?
Not licensed in..?
- 5-HT1 receptor agonists -receptor activation causes cranial vessel vasoconstriction
- Sumatriptan, Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Zolmitriptan
- SIGN recommends Sumatriptan as 1st line option
Try alternative if Sumatriptan ineffective - Use non-oral formulation if vomiting restricts oral intake
Nasal Spray
Subcut. Injection - Not licensed in over 65s
Triptans
C/I?
Contraindications?
CV disorders
TIA/CVA
Severe Hepatic Impairment
Other triptans, MAOIs, Ergotamine
Cautions?
CVD Risk Factors
Elderly
Hx risk factors for seizures
Renal/Hepatic impairment – reduce dose
Counselling?
Take one dose at onset of symptoms
Take another dose if needed at least 2 hours later if migraine/symptoms recur
Max 2 doses in 24 hours
Side Effects?
Dizzyness/Drowsiness
Dyspnoea
Nausea, vomiting, dysphagia
Intestinal ischaemia
Myalgia
Flushing
Fatigue
Epistaxis, nasal irritation, altered taste and throat irritation (Nasal spray)
Anti-emetics:
Examples?
C/I?
Cautions?
Metoclopramide & Prochlorperazine
* Metoclopramide used in nausea treatment in acute migraine but NOT LICENSED
* Metoclopramide not to be used regularly – risk of EPSE, short term use only
* Prochlorperazine buccal tablet for nausea & vomiting
Contraindications:
* GI haemorrhage, obstruction, perforation or recent surgery
* Phaeochromocytoma
* Parkinson’s Disease
* CNS depression
* Liver/Kidney dysfunction
* QT prolongation
* Heart Failure
Cautions:
* Children & young adults
* Renal & Hepatic impairment
* Cardiac disorders
* Elderly
* Hypothyroidism
* Renal impairment
* CV risk factors
Triptans
Drug interactions?
P & BF?
Drug interactions:
* MAOIs – plus 2 weeks after stopping
* MAOI
* CYP 3A4 inhibitors e.g Clarithromycin, Ketoconazole
* Other Triptans – 24hr washout needed when switching
* Other triptans, MAOIs, Ergotamine
SSRIs & SNRIs
* Lithium
* Ondansetron
* St John’s Wort – Risk of Serotonin Syndrome
* Propranolol – Rizatriptan max. dose 5mg & not within 2hrs of each other
Pregnancy
* Limited data
* Avoid unless benefit outweighs risk
Breastfeeding:
* Present in milk
* Too small to be harmful
* Minimise infant exposure
* Avoid feeding for 12 hours after a dose
* Express and discard any milk during those 12 hours
Anti-emetics
What are the side effects of Metoclopramide?
(Same as Prochlorperazine)
Acute dystonias
Diarrhoea
Asthenia
Drowsiness
Depression
Hypotension
EPSE
Drowsiness
Blood disorders
Endocrine disorders
Insomnia
Agitation
Hyponatraemia
SADH
Skin reactions, cardiac dius
Anti-emetics
What are the side effects of Prochlorperazine?
- EPSE (parkinsonism, akinesia, dystonia, akathisia)
- Drowsiness
- Blood disorders
- Endocrine disorders
- Insomnia
- Agitation
- Hyponatraemia
- SADH (syndrome of inappropriate antidiuretic hormone secretion)
- Skin reactions
- Cardiac disorders
- Jaundice
- Muscle rigidity
- Nasal congestion
- Respiratory depression
- Neuroleptic malignant syndrome
Anti-emetics:
What are the interactions of Metoclopramide? (4)
- Levodopa/Dopamine agonists (apomorphine, ropinirole, rotigotine, pramipexole)
- Alcohol
- CNS depressants (TCA, SNRI, SSRI)
- Serotinergics (SSRIs)
What are the interactions of Prochlorperazine?
Alcohol
Amitriptyline
Antihypertensives
CNS depressants
Cabergoline, levodopa, ropinirole
QT prolonging drugs
Carbamazepine
Anti-emetics in pregnancy and BF:
Pregnancy:
Metoclopramide not known to be harmful
But avoid at end of pregnancy due to potential EPSE in newborn depressants
Avoid prochlorperazine unless benefit outweighs risk
Reports of EPSE and withdrawal in neonates if taken during trimester 3
Breastfeeding:
Avoid metoclopramide, small amounts in breast milk
Avoid prochlorperazine – limited data but animal studies indicate adverse effects
Propranolol
Contraindications?
Cautions?
Side Effects?
Drug interactions?
P & BF?
Contraindications:
Asthma & COPD
Cardiovascular
Cardiogenic shock
Hypotension
Bradycardia
Heart lock
Angina
PVD
Heart Failure
Phaeochromocytoma
Cautions:
Diabetes
Myasthenia gravis
Hepatic & renal impairment
Psoriasis
Side Effects:
Hypoglycaemia
CNS – Dizziness, confusion etc
Sleep disturbance, nightmares, depression
Dry eye
Bradycardia, HF, PVD, Hypotension
Cold extremities, Raynaud’s
Bronchospasm, dyspnoea
Diarrhoea, N&V, constipation, dry mouth
Alopecia, psoriasis exacerbation, rash
Sexual dysfunction
Fatigue
Drug interactions:
CCBs, antiarrythmics
Warfarin
Antidiabetics
Antihypertensives
Methyldopa, levodopa
Ergotamine & derivatives
Pregnancy & Breastfeeding:
Avoid in pregnancy
Growth restriction, hypoglycaemia, bradycardia
Avoid in breastfeeding unless essential
Topiramate
What is it used to treat?
Dose?
Contraindications?
Cautions?
SE?
Drug interactions?
BF?
Migraine and Epilepsy (2nd gen AED)
- Initiate at low dose (25mg) and titrate slowly (25-50mg increments) every week
- Highly effective contraception needed prior to starting
- Can impair some hormonal contraceptives
- Women should seek advice if planning a pregnancy
- Use in Scotland restricted – try other prophylactic agents first and only use if others have failed
Contraindications:
Pregnancy
Children
Acute porphyria
Cautions:
Women of childbearing age
Breastfeeding
Risk of metabolic acidosis
Risk of nephrolithiasis
Hepatic & renal impairment
Side effects:
Cognitive impairment, confusion, dizziness, drowsiness
Anxiety, depression, suicidal ideation, sleep disturbances
Cough, dyspnoea
GI disorders
Nephrolithiasis
Skin disorders
Eye disorders
Hyperammonaemia +/- encephalopathy
Joint disorders, muscle weakness
Anaemia
Malaise
Drug interactions:
Oral contraceptives
Carbamazepine
Phenytoin
Valproate
Warfarin
Breastfeeding:
Avoid
Suspend breastfeeding or stop/suspend topiramate treatment if breastfeeding benefit outweighs topiramate benefit
Amitriptyline
Used for?
Dose?
Depression, migraine prophylaxis, neuropathic pain, abdo pain
Dose: 25-75mg at night
SIGN - consider as prophylactic treatment in episodic or chronic migraine
NICE –consider for prophylaxis based on patient preference, comorbidities and risk of adverse effects
Pizotifen:
Who is it indicated for?
Dose?
Cautions?
SE?
Licensed for prophylaxis in young people aged 12-17
On recommendation of specialist
Starting dose 500mcg od, inc. up to 1.5mg daily in divided dose
Contraindications
Acute porphyria
Cautions
Hx epilepsy
Angle-closure glaucoma
Urinary retention
Avoid abrupt withdrawal
Side effects
Increased appetite
Dizziness, drowsiness, sleep disorders
Dry mouth
Fatigue, nausea, increased weight, constipation
Anxiety, depression
What are cluster headaches?
- Classed as a primary headache by ICHD
- Part of a group of headaches called Trigeminal Autonomic Cephalalgias
- Most common Trigeminal Autonomic Cephalalgia
- Frequently recurring, localised, short lasting but severe
- Episodic - attacks in period between 7 days to on year with at least 3 month pain free period between attacks
- Chronic – attacks for 1 year or longer without a pain free period or a period that lasts less than 3 months
- Chronic can become episodic over time or vice versa
Cluster Headache
Pathophysiology is complex and not fully understood
Synchronised abnormal activity in hypothalamus, trigeminovascular system and ANS
Familial link
Environmental factors can trigger attacks – alcohol, smoking, histamine, nitrate containing foods, volatile substances
Rare disorder, hard to assess true prevalence
Peak age of onset aged 20-40yrs
More prevalent in men than women - 3:1 ratio
Impact on work, home and school life
Link with anxiety and depression – fear of pain, relationship issues
Can co-exist with other headaches e.g. Migraine
Cluster Headache - Symptoms?
- ICHD – at least 5 attacks of severe/very severe unilateral orbital, supraorbital and/or temporal pain lasting 15 mins to 3 hrs
At least 1 of:
* Conjunctival injection and/or lacrimation
* Nasal congestion and/or rhinorrhoea
* Eyelid swelling
* Forehead and facial sweating
* Forehead and facial flushing
* Sensation of fullness in the ear
* Miosis and/or ptosis
(small/constricted pupils, drooping of eyelid)
- Restlessness or agitation
- Attacks between one every other day and 8 a day and variance in location of attack within the same bout of between bouts, aching headache between attacks
Cluster Headache – Differential Diagnosis
Tension Headache
Cluster Headache
Paroxysmal Hemicrania
Cough/cold Headache
Trauma/injury to head/neck
Intracerebral Haemorrhage
Central Venous Thrombosis
Giant Cell Arteritis
TIA/Stroke
Idiopathic Intracranial Hypertension
Neoplasm
Substance Withdrawal
Medication Overuse
CO Exposure
Intracranial Infection
Hypoxia
Hypertension
Pre-eclampsia/Eclampsia
Closed Angle Glaucoma
Dental Problem
Otitis Media
Sinusitis
Somatisation Disorder
Cluster Headache – Management:
How to suspect?
How to confirm?
Suspected:
* Suspect based on symptoms/features
* Refer to specialist if present with red flags or secondary headache suspected
* 1st bout – Neurology referral for neuroimaging and confirmation of diagnosis
Confirmed:
* Advice & Support, information, signposting
OUCH UK, Lifting The Burden, Migraine Trust, NHS info, patient.info, BASH
* Assess for triggers
Cluster Headache – What is the pharmacological management used?
Pharmacological Management:
* Triptan therapy for acute attack – over 18s
* Subcut/Nasal Sumatriptan
* Nasal Zolmitriptan
* Oxygen therapy – specialist referral
* Prophylactic treatment – Verapamil – Specialist referral if considered
Headache diary, especially if co-existing with migraine
Regular review to assess response to Treatment
Verapamil
Drug class?
What is it used to treat?
Dose?
Contraindications?
Cautions?
Side effects?
Interactions?
- Calcium channel blocker
- Use in cluster headache prophylaxis is unlicensed
- Dose – 240 – 360mg daily in 3-4 divided doses
- Contraindications – Acute porphyria, AF, bradycardia, HF with reduced ejection fraction, Hx impaired LV function, hypotension
- Cautions – Elderly, acute phase MI, 1st degree heart block, neuromuscular disorders
- Side Effects – Abdo pain, dizziness, drowsiness, flushing, headache, nausea, vomiting, palpitations, tachycardia, peripheral oedema, skin reactions
- Overdose – CCB poisoning signs include nausea, vomiting, dizziness, agitation, confusion, metabolic acidosis, hyperglycaemia, severe hypotension, peripheral vasodilatation
- Interactions – Amiodarone, B-blockers, Statins, Tacrolimus, Phenytoin, Phenobarbital, Lithium
