Transcript Headache - Bradford VTS

Headache
Lawrence Pike
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Tension headache
Chronic daily headache
Analgesic overuse / rebound headaches
Rare causes
Tension headache
– Tension - type headache is most commonly episodic
(occurs less than 15 times per month). It is defined
as chronic when it occurs 15 or more times per month
for a minimum of 6 months.
– Chronic tension headache is the commonest form of
chronic and recurrent headache and often associated
with a sustained contraction of skeletal muscle of the
scalp, jaw and neck. This is sometimes associated
with anxiety and emotional stress.
– Precipitating factors for tension headache include
psychological, social and emotional factors, minor
head injury and CNS infection (e.g. post viral
meningitis).
Chronic daily headache
 Chronic daily headache (overlaps with
chronic tension headache) is a descriptive
term used when there is headache
occurring on more days than not or for
more than 50% of the time. There is often
association with sleep disturbance, anxiety
and analgesic overuse. Family history is
positive in 90% of patients. The cause is
often analgesic overuse.
Analgesic overuse / rebound
headaches
 Usually result from analgesic overuse in chronic
headache sufferers, most commonly with the
use of opioids or ergotamine for the
management of migraine or chronic tension
headache.
 It may also occur when other analgesics are
used over-frequently for headache.
 A chronic daily headache develops after long
term continuous or overuse of the offending
drug and cessation of treatment leads to
withdrawal symptoms (primarily headache).
Rare Causes
• Benign cough headache
• ‘Ice-cream' headache
• Benign Exertional Headache
• Headache associated with sexual activity.
Incidence
• Over 95 % of the population suffer from occasional
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headache.
A much smaller proportion consult their GP with
headache.
Tension headache and chronic daily headache are more
common in women and those with a positive family
history
3% of the population suffer from chronic daily headache.
Up to 1 in 50 people suffer from analgesic overuse /
rebound headache.
Headache has a significant functional impact at work,
home and school.
Examination
• CNS examination including cranial nerves and
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mental state is likely to be normal in tension and
other non-serious headache, but is essential in
order to exclude more serious causes.
Fundoscopy should always be performed to
exclude hypertension (also check blood
pressure) and papilloedema. [Steiner 1997]
Palpation of the face and neck to exclude local
causes.
Exclude meningeal irritation (neck stiffness and
Kernig's sign).
Management
• Identification and exclusion of precipitating factors
• Headache calendar has been found effective in
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identifying possible aetiological factors
Cognitive behavioural therapy with a view to improving
coping strategies is sometimes effective
Discussion with regard to lifestyle changes in order to
reduce stress and anxiety, may be of value.
Relaxation therapies and postural advice are effective if
used appropriately.
Drug Management
• Paracetamol, aspirin and other NSAIDs are effective in
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the treatment of headache.
Codeine should be used with caution because of the
increased chance of causing analgesic rebound
headache.
Low dose combination codeine preparations have been
shown to be of no greater efficacy than paracetamol
alone.
High dose codeine (30mg) may be used for patients with
severe headache as it is an effective painkiller for severe
pain but this must be short term (less than one week)
only.
Management cont.
• Analgesic overuse rebound headache is treated
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by stopping the analgesic. An alternative
analgesic used at recommended frequencies and
doses can be helpful
In severe, chronic tension headache, prophylaxis
with tricyclic antidepressants and betablockers if
there are migraine-like symptoms may be used
Acupuncture: there is little supportive evidence
of its benefit