Migraine, Tension and Medication Overuse Headache

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Migraine, Tension and Medication Overuse Headache

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Primary Headache Syndromes
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Secondary Headache Syndromes
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Headache

• Common
• 20 New patient referrals to neurology clinic
• Mostly Tension Headache/ Migraine

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Migraine Definition

• Familial Paroxysmal neurological disorder
  characterised by spontaneous or triggered attacks
  of headache that are variably associated with-
• Autonomic disturbance (nausea , pallor
• Heightened sensitivity to external stimuli
  (Light, noise, smell)

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Migraine Attacks

• Last 4-72 hours (often shorter in children)
  sometimes longer in adults
• Frequency variable.
• 25 sufferers one attack per week
• Some develop chronic migraine occurring on more
  days than not

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Migraine Attacks

• Classical/ migraine with aura
• Common/ migraine without aura

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Migraine without Aura

• Common Migraine
• Occurs at any age
• Commonest middle /older
• Not always prior history of migraine

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Migraine without Aura

• At least 5 attacks with following features
• Headache lasts 4-72 hours
• Unilateral
• Pulsating
• Moderate or severe intensity
• Aggravate by physical activity or causes
  avoidance of
• Photophobia and phonophobia
• Nausea or Vomiting

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Associated features

• Nausea 90
• Vomiting 50
• Photophobia
• Phonophobia
• Irritability
• sleep

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Useful Questions

• Does light bother you a lot when you dont have
  headaches?
• Do your headaches limit your ability to work,
  study or do what you need to for at least 1 day?
• Do you feel nauseated or sick?

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Migraine Phases

• Prodrome -fluid retention, food craving,
  tiredness, mood swings
• Aura phase
• Headache phase-vasodilatation

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Migraine Pathophysiology

• Migraine threshold-a wave of depolarisation
  spreads across the cerebral cortex from occipital
  to frontal regions - rate of 2-3 mm/min
• resulting in brain ion dysfunction secondary
  vasoconstrictor vascular events. 
• Changes account for the progression and variety
  of symptoms that occur during the Prodromal and
  Aura Phases

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Headache Pathophysiology 1

• Direct stimulation (via the thalamus) of the
  cortical pain areas situated in higher centres of
  the CNS which produce the pain of headache
• Direct effects and the secondary vasoactive
  responses account for the headache in patients
  who have migraine attacks without the aura.

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Headache Pathophysiology2

• Trigeminovascular activation
• Release of inflammatory neuropeptides-in the
  trigeminal vascular system-
• Substance P
• Neurokinin A
• Calcitonin gene-related peptide -vasodilation.

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Mechanisms in Migraine

• Increased 5 HT-at onset of aura
• Platelets release 5HT
• Decreased 5HT during headache
• Histamine release
• Altered vascular permeability
• Release of other kinins
• Vascular dilatation
• Increased pain sensitivity
• Magnesium deficiency
• Neural excitation by glutamate/aspartate

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Trigger Factors

• Dietary-foods, alcohol,hunger, caffeine
  withdrawal
• Sleep Related-deprivation, excess, irregular
• Hormonal-menstrual,O.C.,menopause, HRT
• Physiological-fatigue, travel,exercise,smoking
• Emotional -anxiety, stress, relaxation post
  stress, excitement
• Physical- neck/back injury, head trauma,
  hypertension

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Environmental Factors

• Flickering lights
• Sunlight/ Bright lights
• Heat
• High altitude
• Loud noise
• TV/ VDU screens
• Strong smells
• Meterological changes
• Barometric Changes

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Migraine aura-Visual

• unilateral scotoma
• Hemianopia
• Teichopsia-flashes of light
• Fortification spectra

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Migraine variants

• Basilar
• Hemiparetic
• opthalmoplegic

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Basilar migraine-Brainstem Features

• Circum oral tingling, tongue numbness
• Vertigo
• Nausea and vomiting
• Diplopia, Hemianopia/blindness
• Nystagmus
• Dysarthria
• Ataxia
• Tinnitus
• Syncope

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Hemiplegic Migraine

• Sporadic or Familial-rare
• Attacks may be precipitated by minor head injury
• Calcium channel subunit mutationRare
• Aura-hemi paresis
• /- migrainous headache
• Usually recover in 24 hours
• Occasional cerebral infarct

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Opthalmoplegic

• Migraine headache
• 3rd or 6th Nerve palsy

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Investigations

• Classic history-not necessary
• First-time Aura, complex aura with motor,
  sensory, brainstem symptoms-MRI Brain

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SIGN Guidelines

• www.sign.org.uk

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Treatment-Attacks-1

• Paracetamol, Aspirin
• NSAIDs-Tolfenamic acid 200mg/ Aspirin 900mg,
  Naproxen 500mg, ketorolac-iv/im
• Anti-emetics-Domperidone, metaclopramidepo/iv/im,
  prochlorperazine-po/iv/im
• Dihydroergotamine iv,im,sc
• Ergotamine tabs

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Attack Treatment 2

• Vomiting or nausea use injectable or nasal
  preparation
• Triptans-avoid in aura phase,
• complex auras and Ischaemic Heart dis.
• Contra indicated in true Hemiplegic migraine

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Migraine treatment 3

• Droperidol-0.625mg every 10min av 3.15mg
• Dexamethasone-8-20mg iv,Hydrocortisone100-250mg
  iv 8-12 hrly for 24hrs
• Sodium valproate iv

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Sub-optimal response to One Acute drug

• Antiemetic Domperidone
• May need combination
• NSAID-Tolfenamic acid
• Triptan-Sumatriptan-most effective

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Triptan Non-Response

• Dont consider Triptan non-responder until all
  varieties tried

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Cautions

• Excess use of Triptans More than 10 times per
  month-Medication overuse headaches-migrainous
  quality
• Opiates- may be used sparingly-overuse-habituation
  , dependence, medication overuse headaches,
  resistance to other acute headache remedies

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Migraine Prevention

• More than 4 disabling attacks per month- special
  circumstances
• Aim-50 reduction severity and frequency
• Require regular medication
• Gradual increased titration until positive
  response, max dose and no response, or
  intolerance due to side-effects

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Preventative Medication 1

• Best evidence-Beta-blockers (all except those
  with intrinsic sympathetic activity
• Commonest- PROPRANOLOL, timolol, metoprolol,
  nadolol, atenolol
• Tricyclic antidepressants Amitriptyline ,
  Nortriptyline, Dosulepin

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Prevention/Prophylaxis 2

• Sodium Valproate
• Topiramate
• Gabapentin
• Venlafaxine
• Calcium channel blockers-Flunarizine, verapamil
• Antiserotonin-Pizotifen, Methysergide

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Prevention 3 Other options

• Menstrual migraine-usually due to falling
  oestrogen in 2nd half cycle-
• consider Oestradiol patch(100mcg /day),B.D NSAID
  or b.d triptan starting 2days before period due

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Non-drug therapy

• Headache diary-look for and avoid triggers
• Relaxation exercises
• Cognitive behavioural therapy

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Differential Diagnosis of Migraine

• Sudden onset- Subarachnoid haemorrhage
  meningitis
• Hemi sensory /Hemiplegic /visual
  symptoms -TIA/CVA
• Unilateral paraesthesia-sensory epilepsy

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Differential Diagnosis Subacute Migraine

• Tension Headache
• Medication overuse Headache

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Benign Headache Continuum
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Tension Headache-Pain Quality

• Tight band sensation
• Pressure behind eyes
• Pressure on vertex
• Bursting sensation

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Tension Headache-clinical signs

• Normal neurological examination
• Tenderness neck and scalp muscles

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Tension Headache- Causes

• Stress / worry
• Noise
• Fumes
• Cervical spondylosis
• Minor head injury

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Tension Headache

• Very common
• Chronic recurrent headache
• Cause-tension scalp/neck muscles
• 70 have features of Affective disorder

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Tension headache-Clinical features

• Mild moderate severity
• Pressure sensation,
• Vice-like
• Occipital/ bitemporal or parietal
• Last 30 min- 7 days-constant
• Often worse towards end of day

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Tension Headache and Depression

• Low mood
• Tearfulness
• Low self esteem/self worth
• Poor sleep
• Early-morning wakening
• Poor appetite
• Fatigue
• Suicidal thoughts

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Tension Headache-Management 1

• Firm reassurance / (Imaging)
• Avoidance of causes
• Analgesics-limited amount-
• NSAIDS best
• Avoid codeine containing compounds

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Tension Headache- Management 2

• Antidepressants-tricyclics e.g Amitriptyline
• Beta-blockers
• Relaxation exercises
• Treatment of underlying depression or anxiety
• Cognitive behavioural therapy
• Massage
• Ice-packs
• Acupuncture

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Chronic Daily Headache

• Very frequent more 15 days per month
• Secondary-acute headache medication overuse,
  head trauma, disorders of intracranial pressure

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Medication Overuse headache 1

• Headache more than 15 days per month
• Regular overuse of medication for more than 3
  months-triptans, ergotamine, opioids or opioid
  combinations-Dihydrocodeine, co-codamol,
  co-proxamol-10days per month

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Medication Overuse 2

• Simple analgesics more than 15 days per month
• Total exposure of all acute medication more than
  7 days per month
• Headache developed or markedly worsened with
  medication overuse
• Headache resolves or reverts to previous pattern
  within 2 months of discontinuation of overused
  medication

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Management Medication Overuse headache

• Acute medication withdrawal
• Regular eating, sleeping, exercise pattern
• Avoid/ limit caffeine
• Relaxation and biofeedback techniques

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Withdrawal symptoms

• Severe headaches, nausea, vomiting, restlessness,
  agitation, sweating, insomnia
• May occur for 2-10 days
• Usually headache swill improve significantly in
  4-8 weeks
• Generally manage as OP
• 4year relapse -50

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Guidelines

• www.sign.org.uk
• www.bash.org.uk

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The End