Headaches

1. Headaches GPVTS Teaching NarcisRugina 27 June 2012

2. Intro 80 % of people in the UK affected at some time in their lives One of the most frequent causes of consultation in general practice and neurological clinics Migraines – 15% of the UK adult population (women:men=3:1)1 - 100,000 people absent from work/school1 (£1.5 billion/annum cost to the economy) There is evidence that headache disorders are under-diagnosed and under-treated in the UK2

3. International classification of headache disorders Primary 1.Migraine, including: • 1.1 Migraine without aura • 1.2 Migraine with aura 2.Tension-type headache, including: • 2.1 Infrequent episodic tension-type headache • 2.2 Frequent episodic tension-type headache • 2.3 Chronic tension-type headache 3.Cluster headache and other trigeminal autonomic cephalalgias, including: • 3.1 Cluster headache 4. Other primary headaches

4. International classification of headache disorders(cont) Secondary 5. Headache attributed to head and/or neck trauma, including: Chronic post-traumatic headache 6. Headache attributed to cranial or cervical vascular disorder, including:headache attributed to subarachnoid haemorrhage and headache attributed to giant cell arteritis 7. Headache attributed to non-vascular intracranial disorder, including: headache attributed to idiopathic intracranial hypertension and headache attributed to intracranial neoplasm 8. Headache attributed to a substance or its withdrawal, including: Carbon monoxide-induced headache, Alcohol-induced headache, Medication-overuse headache, Ergotamine-overuse headache, Triptan-overuse headache and Analgesic-overuse headache

5. International classification of headache disorders(cont) • 9.Headache attributed to infection, including: Headache attributed to intracranial infection 10. Headache attributed to disorder of homoeostasis 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures, including:11.2.1 Cervicogenic headache; 11.3.1 Headache attributed to acute glaucoma 12. Headache attributed to psychiatric disorder Neuralgias and other headaches 13. Cranial neuralgias, including 13.1 Trigeminal neuralgia 14. Other headaches, central or primary facial pain

6. Diagnosing headaches • 1. Taking good history - why consulting you now ? - onset, frequency, temporal pattern, how long lasting; - intensity, nature/quality of pain, site and spread, associated sptms; - predisposing/trigger factors, aggravating/relieving factors, ?family hx; - what does the patient do during the headache ? (is activity limited/prevented ?); - what medication has been used and in what manner ?; - between attacks: completely well ?, residual sptms ?

7. Diagnosing headaches (cont) • Warning features: - new or unexpected; - thunderclap - aura>1hr or including motor weakness; - aura first time in a patient using COC; - new onset if >50yo; - new onset if <10yo; - persistent morning headaches with nausea; - associated with postural change; - new onset in a patient with cancer/HIV.

8. Physical examination - Brief (but comprehensive) neurological examination: Romberg, walk on toes/heels, outstretched arms, finger-nose, finger-hand, visual fields, eye movements, face (all of the above can be done in 60 seconds !) + reflexes, plantars, fundoscopy. (http://www.youtube.com/watch?v=fgwN1P5DaA) - BP measurement (it is said that raised BP do not cause headache, patients believe otherwise); - examination of head and neck for muscle tenderness, stiffness, limitation of ROM, crepitation – often revealing, especially in TTH; Performing all of the above repays the time spent through its therapeutic value. Only 0.9% of headaches without neurological signs have significant pathology3 .

9. Imaging • Only if secondary causes suspected. • Therapeutic value/anxiolytic effect of a normal brain scan not sustained beyond a few months4. • Cervical spine Xray – usually do not alter management. Serious causes • Meningitis • Subarachnoid haemorrhage • Intracranial tumour • Giant cell arterits • Primary angle-closure glaucoma • Idiopathic intracranial hypertension • Carbon monoxide poisoning (stereotype exam question: student comes with headache, lethargy, nausea)

10. IHS diagnostic criteriafor Migrainewithout aura • A. At least 5 attacks fulfilling criteria B-D • B. Attacks lasting 4-72hrs (shorter in children, common bilateral, GI sptms prominent) • C. At least two of the following: 1. Unilateral 2. Pulsating 3. Moderate or severe 4. Aggravated by or causing avoidance of routine physical activity (ie walking) • D. At least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia • E. Not attributed to another disorder

11. IHS diagnostic criteria for Migraine with aura • A. At least two attacks fulfilling three or more of the following: 1. One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain stem functions. 2. At least one aura symptom develops gradually over more than four minutes, or two or more symptoms occur in succession. 3. No aura symptom lasts more than 60min; if more than one aura symptom is present, accepted duration is proportionally increased. 4. Headache follows aura with free interval of at least 60min (it may also simultaneously begin with the aura. • B. At least one of the following aura features establishes a diagnosis of migraine with typical aura: 1. Homonymous visual disturbance. 2. Unilateral paresthesias and/or numbness. 3. Unilateral weakness. 4. Aphasia or unclassifiable speech difficulty.

12. Migraine - treatment • Use treatment ladder; go to next step if failure on three occasions with previous step medication. • Step 1: a) Aspirin 600-900mg-qds or Ibuprofen 400-600mg-qds (Little evidence for the efficacy of Paracetamol alone50 !) +/- Antiemetics: Prochlorperazine 3-6mg buccal tablet (max twice in 24hrs)51 or Domperidone 10mg qds b) Naproxen 750-825mg stat53,54,55 with further 250-275mg up to twice in 24hrs or Diclofenac-potassium 50-100mg56,57,58 repeated up to 200mg/24hrs + Prokinetic antiemetics: Metoclopramide 10mg or Domperidone 20mg61 Combinations: MigraMax (lysine acetylsalicylate 1620mg-equiv of Aspirin 900mg + Metoclopramide 10mg) tds; Paramax sachets (Paracetamol 500mg + Metoclopramide 5mg), 2 sachets tds.

13. Migraine – treatment (cont) • Step 2: Rectal analgesic +/- antiemetic - Diclofenac supp 100mg, bd +/- Domperidone supp 30-60mg, up to 120mg/24hrs. • Step 3 : Specific anti-migraine drugs - 30% fail to respond - if poor response to one triptan, can benefit from another in subsequent attacks - Triptans must be taken at the start of the headache phase69 , NOT during aura70,71 Examples: - Sumatriptan, 50mg tablet or rapidly-dispersing RADIS 50mg tablet; if inadequate response, 100mg or 20mg (10mg for 12-17yo) nasal spray can be used (max 300mg PO or 40mg intranasally). For rapid response – 6mg subcut (max 12mg/24hrs).

14. Migraine – treatment (cont) • Zolmitriptan 2.5mg (RAPIMELT-orodispersible) - second dose can be taken in 2 hours; for recurrences – 5mg initially (max 10mg/24hrs); Nasal spray 5mg. • Rizatriptan 10mg (max 20mg/24hrs) Contraindications to step 3: uncontrolled HTN, risk factors for coronary heart disease and children under 12yo. • Step 4 : Combinations - Sumatriptan 50mg + Naproxen 500mg superior to either drug alone95 - steps (1 + 3) followed by steps (2 + 3)

15. Migraine – treatment (cont) • Relapses: Naratriptan, Eletriptan and Frovatriptan – low recurrence rates104. Ergotamine 1-2mg, significantly lower recurrence rate93, better as suppositories, max 4mg/24hrs; not to be taken concomitantly with any triptan. • Prophylaxis: 6-8/52 titration doses, if effective – continue 4-6/12. -1st line: -Beta-blockers110,111 (CI - asthma, heart failure, PVD, depression) – Atenolol (25-100mg BD), Metoprolol (50-100mg BD), Propranolol (80mgOD-160mgBD). N.B.No evidence for effectiveness in Chronic Migraine ! -Amitriptyline (10-150mg), Nortriptyline, Dothiepin, if associated with disturbed sleep, TTH, depression, another chronic pain condition. -2nd line: Topiramate (25mg OD – 50mg BD)113,114,115, Sodium valproate (300 – 1000mg BD)116,119

16. Migraine – treatment (cont) • Prophylaxis: -3rd line: Gabapentin (300mg OD – 800mg TDS), little evidence121 Methysergide (1-2mg TDS)122 Synergistic effect of combining B-blocker + Amitriptyline (no formal evidence) Limited efficacy: Pizotifen123, Clonidine124, Verapamil. Menstrual attacks of migraine: Frovatriptan for 6days (5mg BD on day 1, 2.5mg BD on days 2-6) starting 2 days before the expected onset of migraine139,140. Also, transdermal estrogen 100mcg, a 7day patch, 3days before the onset of menses; Estradiol gel (1.5mg in 2.5g gel). HRT in women with migraine – no contraindication.

17. Migraine – treatment (cont)… and the last • Non-drug intervention - physical therapy163, acupuncture164 , psychological therapy (relaxation therapy, stress reduction and coping strategies, yoga and meditation); - homeopathy – no value165,166,167 - hypnotherapy – unproven value - reflexology – no scientific basis

18. Tension-type headache (TTH) • A) First measures: - regular exercise, physiotherapy (massage, mobilisation, manipulation, correction of posture); - when stress-related: life-style changes, relaxation therapy, cognitive training to develop stress-coping strategies. • B) Drug therapy: - Aspirin 600-900mg, Ibuprofen 400mg, Ketoprofen 25-50mg, Naproxen 250-500mg - Paracetamol – less effective175 ! -Avoid Codeine, Dihydrocodeine, opiates. - Frequent, unremitting TTH ? Give 3/52 course of Naproxen 250-500mg BD may break the cycle. Treatment of choice remains Amitriptyline, titrating from 10-25mg with increments of 10-25mg every 1-2/52, up to 150mg at night.

19. Tension-type headache (TTH) • Often refractory. • Association with personality factors of psychosocial dysfunction – suspected but not consistently demonstrated. • Cognitive therapies, TENS may be offered. • Acupuncture – unproven but worth trying180. • Homoeopathy – unknown value.

20. Cluster headache (CH) • Better left to experienced specialists who see this disorder frequently. • Poor understanding of underlying mechanism. • Prophylaxis – mainstay of treatment: - Verapamil 80mg tds or qds (up to 960mg daily required). Check ECG before dosage reaches 480mg and whenever is increased after that. No concomitant beta blocker use. - Prednisolone186 60-100mg daily for 2-5 days - Lithium - Methysergide 1-2mg tds may be effective in 70%, worth trying when other treatments fail. - Ergotamine 1-2mg suppository at night • Acute treatment: Sumatriptan 6mg subcut195,196 ; Oxygen 100% at 10-15l/min, 10-20 min helps some people-unlicensed.

21. Medication-overuse headache (MOH) • According to ICHD-II (2004): • Simple analgesics (taken >15 days/month for >3 months), as well as combination analgesics, opioids, ergots, and triptans (taken at least 10 days/month for >3 months), can lead to this phenomenon. • MOH includes the following features: • 1) headache frequency increases over time; • 2) patients often awaken early with headache (despite this not being a feature of original headache); • 3) a proportion of attacks may become nondescript, losing migrainousor autonomic features, and begin resembling tension-type headache; • 4) a lowered threshold for stress or exertion to precipitate headaches is present; • 5) escalating doses of analgesics are required; and • 6) headaches occur within predictable time frame after analgesic consumption, with reduced efficacy.

22. Medication-overuse headache (MOH) • Management: - outpatient medication withdrawal (exclusion criteria – severe nausea, vomiting, dehydration, use of strong opiates, barbiturates, tranquilisers, uncontrolled HTN); - the most important approach is the explanation of the rationale and purpose of medication withdrawal (PET scans showed hypometabolism in brain areas known to be involved in pain processing; in 3/52 these changes resolve after meds withdrawal197) - warn patients that they may experience a transient worsening of their headaches - arrange review; - if analgesics are re-introduced, no more than 2 days/week !

23. Medication-overuse headache (MOH) • Management (2): - allow NSAIDS as rescue medication – Naproxen 500-1000mg/day; Can be used as preventative medication to break cycle – 250mg TDS for 2/52, then BD for another 2/52 and OD for last 2/52 - introduce a prophylactic medication immediately (Amitriptyline, sodium valproate, topiramate) - greater occipital nerve infiltration with lidocaine and depo-medrone, particularly where point tendernes of the nerve accompanies chronic ipsilateral head pain; - last resort, admission, iv Aspirin 1gtds, iv sodium valproate up to 2g /day, or iv dihydroergotamine 1mg tds - Relapse rate high - 1/3 -1/2;

24. Medication-overuse headache (MOH) • Management (3): - However, 81% had a decreased severity or frequency of at least 50 percent after two months, and 61% maintained this at 1 and 4 years follow up198.

25. Also… • Chronic daily headache: - Chronic migraine - at least a 3-month history of headaches occurring >15 days/month, meeting criteria for migraine on >8 days/month, in the absence of medication overuse - Chronic TTH, - Hemicrania continua and - New daily persistent headache (NPDH) - acute constant unremitting headache, developing over less than 3 days. Patients often pinpoint the exact calendar date, often the exact hour, of headache onset. In NPDH, a search for secondary causes is mandatory, given treatment attempts for NDPH are often less successful. - Medication overuse headache - Chronic post-traumatic headache

26. Patient satisfaction • Hospital Clinic attenders = 72% • GPwSI Clinic attenders = 79%199 (in terms of waiting time, ease of access, being listened to and understood, the help they had received, the extent to which their needs were met, symptoms relief, ability to deal more effectively with their problems)

27. Bibliography • BASH (British Association for the Study of Headache), 3rd edition, 2010 (and its bibliography list). • 1. Steiner TJ, Lipton R. The prevalence and disability burden of adult migraine in Enhland. Cephalgia 2003; 23: 519-527. • 2. American association for the study of headache, International Headache Society. Consensus statement on improving migraine management. Headache 1998; 38: 736. • 3. Sempere A, Porta-Etessam J. Neuroimaging in the evaluation of patients with non-acute headache. Cephalgia 2005; 25: 30-35. • 4.Howard L, Wessely S. Are investigation anxiolytic or anxiogenic ? RCT of neuroimagingto provide reassurance in chronic daily headache. J Neurol Neurosurg Psychiatry 2005; 76: 1558-1564. • **********BASH**** • 197. Fumal A, Laureys S, Di Clemente L, et al. Orbitofrontal cortex involvement in chronic analgesic overuse headache. Brain 2006; 129:543-550. • 198. Freitag FG, Lake A III, Lipton R, et al. Inpatient treatment of headache: an evidence-baseed assessment. Headache 2004;44:342-60. • 199. Ridsdale et al. BJGP, 2008.