Transcript headaches - Bradfordvts

Headache
HEADACHES
PRIMARY CARE MANAGEMENT
Headaches-overview
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Primary headaches
-Migraine
-tension type
-cluster headache/cephalgias
-Others
Headache classification
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Secondary headachesTrauma
Cranial/ cervical vascular disorder
Substance or its withdrawl
Infection
Homeostasis related
Neck , sinuses,eyes,nose, teeth
Anxiety/somatisation
Headache classification
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Neuralgias/other headaches
Eg cranial neralgias, trigeminal neuralgia,
atypical facial pain
Headaches
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Affect 40% of UK population
Migraine- 15% of population.
Females:males 3:1
Tension headaches- 80% of population
Cluster headache 1 in 200
MIGRAINE
Migraine
Migraine management
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Look at predisposing factors
-stress,
fatigue,depression,anxiety,menstruation,
menopause, head/neck trauma.
-trigger factors-dietary (20%), relaxation,
travel, missing meals/sleep, bright lights,
noise, strenuous exercise, mensruation.
Migraine
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Duration (hours3 days)
Without aura in 2/3rd -unilateral, pulsating,
moderate/severe intensity, aggravated by
exercise, nausea/vomiting.
Photophonophobia
With aura in 1/3rd- spreading scintillating
scotoma, unilateral paraesthesia, dysphasia
Migraine-drug intervention
Step one- simple analgesic+/- antiemetic
Eg aspirin 600-900mg +buccastem 3-6mgbd
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Step two – rectal analgesic +/- antiemetic
Eg diclofenac suppositaries+domperidone
suppositaries
Step three – triptans-use at onset of pain, not
aura. Some rebound of symptoms in 20-50%
of patients within 48 hours.
Triptans
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Sumatriptan 50-100mg
Zolmitriptan 2.5mg then rpt after 2 hours (not
children)
Rizatriptan 10mg (equiv sumatriptan 100mg)
Almotritan 12.5mg-HIGH EFFICACY. COST
EFFECTIVE
Migraine prophylaxis
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Ineffective for medication overuse headaches
Use for 4-6 months-taper off over 2-3 weeks.
Agents: betablockers, TCAD, pizotifen,
gabapentin, lisinopril
Other agents-topiramate, sodium valproate,
clonidine
Non drug therapies
Tension headache
Tension headaches
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Chronic tension type headache:-more than 15 days per month
- often daily
-often stress/lifestyle related
Tension headaches
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Episodic tension-type headache-may be unilateral but tend to be generalised
- pressure/tightness
- often spreads from neck
-stress related or related to cervical/cranial
musculoskeletal anomalies
Tension headache management
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Lifestyle changes
Regular exercise
Drug treatments-acute-aspirin 600-900mg,
ibuprofen 600mg, naproxen 250-500mg,
paracetamol 500mg-1g
Prophylaxis-amitriptyline, nortriptyline,
propranolol, SSRIs
Medication overuse headaches
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Affects 1 in 50 adults
Females:males 5:1
First noted with phenacetin/ergotamine
More common with aspirin/
NSAIDs/paracetamol/codeine/DF118
Can take several weeks to resolve after
medication withdrawl
Key feature-pre-emptive use of analgesia
Medication overuse headaches-cont.
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Low doses daily carry larger risk than higher
doses weekly
Esp common if using simple analgesia more
days than not per month
Using triptans, codeine >10days per month
Worse on awakening in the morning
Worse after physical exertion
Medication withdrawl headache-treatment
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Stage one-abrupt withdrawl most effective-Sx
will worsen in days 3-7.
Stage 2-recovery from MOH
Stage 3- review and assess the underlying
primary headache disorder
Stage 4- prevent relapse
Failure to withdraw- naproxen
250mgtds/500mg bd, tcad.
References
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Mentor/GP notebook
BASH (British Association for the Study of
Headaches)-guidelines. www.bash.org.uk
Neurological Differential diagnoses. Batten, J.
2nd edition.