primary or secondary

BASH

Red flags

Age

• new onset >50yo

• new onset \<10yo

Characteristics

• headache new or unexpected

• progressive headahce - worsening over weeks or longer

• Persistent headache precipitiated by Valsalva + postural

• Thunderclap headahce

• persistent morning headache with nausea

Additional features

• headache with atypical aura

  • duration >1hr

  • motor weakness

• Aura for first time in a patient during use of COC

• new onset headahce in apatient with history of cancer

• new onset headhace in patient with history of HIV

• neurological signs

• seizures

• symptoms/signs of GCA

slow growing frontal lobe tumours particularly liable to be silent

present with non-specific headache and subtle personality changes

serious causes:

1. intracranial tumours

2. meningitis

3. subarachnoid haemorrhage

4. GCA

5. Primary angle-closure glaucoma

6. Idopathic intracranial hypertension

   1. young woemn

   2. strongly associated with obesity

   3. papilloedema present

7. CO poisoning

history

• how many different headahce types?

• Time questions

  • why now?

  • recent?

  • frequnet/temporal?

  • long lastign?

• Character questions

  • intensity?

  • nature/quality?

  • site adn spread of pain

  • associated symptoms

• Cause

  • predisposing/trigger

  • Aggravating and/or relieving factors

  • FHx similar

• Response

  • what does patient do

  • how much activit/function limited

  • medications

• state of health between attacks

  • well/residual/persisting

  • concerns/anxieiteis, fears about recurrent attacks

minimal examination

• Fundoscpy

• visual acuity

• bp

• examination of head and neck for muscle tenderness, stiffness, ROM and crep

• Headache diary are useful

Migraine

• typically:

  • recurrent episodic moderate or sevrere headahces (may be unilateral and/or pulsating) lasting part of a day or up to 3 days

    • associated with GI symptoms

    • limit activity and prefer dark and quiet

  • free from symptoms between attacks

• features common in migraine but not usual in TTH

  • aura - 1/3

  • unilateral headache

  • hypersensitivity

  • GI symptoms

IHS diagnositc criteria - migraine without aura

• at least 5 attacks

• last 4-72hrs

• headaches have ≥ 2:

  • unilateral

  • pulsating

  • moderate/severe

  • aggravation by or causing avoidacne of routine physical activity

• During headahce ≥ 1

  • N and or V

  • photophobia/phonophobia

• not anything else

Migraine with aura

• 1/3 of migraine sufferers

• typical aura

  • 5-60mins

  • visual blurring and ‘spots’ are not diagnostic

  • transient hemianopic disturbacne or scintillating scotoma

  • some cases vidual symptoms

    • together or in sequence with other reversible focal neurological distrubances

• in older patients

  • visual migranous aura may occur wihotu any further development of a migraine attach

  • not alarming

• may have attacks of migraine with or without aura

managmenet

1. lifestyle/avoid triggers

   1. stress

   2. depression

   3. anxiety

   4. head/neck trauma

   5. menopause

   6. bright lights/loud noise

   7. dietary triggers

      1. etoh

      2. cheese

   8. unaccustomed strenuous exercise

2. Acute

   1. Step 1: Simple oral analgesic +/- anti-emetic

      1. aspirin, ibuprofen

         1. without codeine

         2. early in the attack

            1. absorption less affected by gastric stasis

      2. prochlopreaizne

      3. domperidone

      4. metoclopramide

         1. promotes gastric emptying

         2. even when N+V not present

         3. on its own gives relief

      5. (Step 2: rectal analgesic +/- anti-emetic)

   2. Tier 2: specific antimigraine

      1. Triptans

         1. Sumatriptam

            1. 50mg orally

               1. 100mg can be triedin future attacks if 50mg ineffective

            2. 6mg sub cut

         2. Rizatriptan

            1. Rizamelt 10mg orodispersable

         3. unpredictable individual variations in response to different triptans

         4. taken at start of headache phase

            1. ineffective during aura

         5. associated with reutrn of symptoms wihitn 48hrs

            1. 20-50% who initially respond

         6. take with metoclopramide

         7. contraindicated:

            1. cerebrovascular disease

            2. coronary heart disease

            3. uncontrolled hypertension

            4. severe hepatic impairment

            5. concurrent use or use within 2 weeks after discontinuation of MAOi

         8. second dose only if first dose effective

      2. Ergotamine

         1. limited by significant risk of toxicity and drug interactions

         2. side effects

            1. n & v

            2. parasthesia

            3. convulsive and gangrenous effects of erotism

         3. Contraindications

            1. cardiovascular and cerebrovascular diseases

            2. Raynaud’s diseaese

            3. arterial htn

            4. renal failure

            5. pregnancy

            6. breast feeding

         4. lower relapse rate compared to sumtripatn

         5. may be useful if relapse an issue

         6. available with caffeine

            1. cafergot

            2. 1mg ergotamine, 100mg caffeine

            3. 2 intially then further 1 30 mins if needed

            4. max dose in 24horus = 6mg and max 10/week

   3. step 4:

      1. combination

      2. chlorpromazine

      3. avoid opiate

3. Prophylaxis

   1. reduce number of attacks

   2. 6-8wks reasonable

   3. First line

      1. Betablockers

         1. atenolol > metoprolol > propranolol

      2. Amitriptyline 10-150mg daily

         1. first line when:

            1. troublesome TTH

            2. chronic pain

            3. disturbed sleep

            4. depression

   4. Second line:

      1. topiramate

         1. enzyme inducer

            1. reduces efficacy of OCP

            2. unlikely to have clinically signifiant effect on hormonal contraception @ doses \< 100mg /day

      2. sodium valproate

   5. Third line

      1. Gabapentin

      2. combine betablockers and amitrip

Tension type headache

• episodic tension type headahce

  • attack like episdoes

  • variable often very low frequncy and short lasting

  • may be unilateral

  • more often generalised

  • pressure/tightness

  • spreads into or arises from neck

  • stress or associated with functional or structural msk abnormal

• chronic tension type headache

  • >15d / month

  • may be daily

management

• simple analgeisa

• nsaids

• paracetamol less effective

• amitriptyline

• botulinum ineffective

-

Cluster headache

• trigminal autonomic cephalalgias

  • daily occurence of headache usual

• mostly affects men

  • 6:1

  • in 20s

• occur in bouts for 6-12 weeks once/year or 2 years - often @ same time

• intesne pain

• strictly unilatearl

  • most often focused in 1 or other eye

• daily at similar time

• often at 1-2 hrs after falling asleep

• patient unable to stay in bed, paces room

• may beat head on wall or floor - 30-60mins

• autonomic

  • ipsilateral conuunctival injection

  • lacrimation

  • rhinorrhoea

  • nasal blockage

  • ptosis

managment

• Reassurance

• Oxygen

• Prophlactic

  • verapamil

  • prednisone

  • lithium

• acute

  • sumatriptan

  • oxygen

  • analgesia has no place

medication overuse headahce

• 1:50 adults suffer

• combination analgesics prime candidates for development of MOH

• regular intake of simple anagesics on 15 or more days / month or codeine/triptan/ergot on 10 or more day s/ month

• low doses daily >> larger doses weekly

• highly variable headache

  • oppressive, presenta nd worset on awakening in morining

  • increases physical exertion

• change to pre-emptive abalgesia = key