Headache diagnosis and treatment : now and the future

1. Headachediagnosis and treatment :now and the future Paul Rolan MBBS MD FRACP FFPM DCPSA Professor of Clinical Pharmacology Senior Consultant, Pain Management Unit, RAH

2. Headache • in 99.9% of people with headache there is no sign of tissue damage • injuring the brain itself does not cause pain – it causes altered brain function • however the membrane and blood vessels of the brain are very pain sensitive

4. Primary (99%+) Tension – type 69 Migraine 16 Stabbing 2 Exertional 1 Cluster 0.1 Due to something else (<1%) Systemic infection 63 Head injury 4 Vascular / bleeding 1 Braintumour 0.1 Headache: causes

5. Headache diagnosis • almost entirely on the patients story • tests, scans etc rarely helpful.

6. Headache: history • How old were you when the headaches started? • How often do they come? • Do they come in relationship to anything else? • At what time do they come on? • How do they start? • Where is the pain? • How long does it last? • How bad is it? • Are there other symptoms? • Does anything bring it on? • What helps? • How long does it last?

7. Pattern recognition pick the odd one out

8. Frequency chronic often daily Painmild-moderate pressure, tightness Duration30 mins - 7 days Locationboth sides whole head and neck Symptomsno light / sound sensitivity no aura Tension-type Headache Typical patient : any

9. Typical patient : any

10. Tension-type headache • now thought to be due to increased brain sensitivity to normal sensory inputs • few effective treatments : we are trialling a non-drug treatment

11. Migraine (“half-head”) Frequency1-2/year- 2-3/week Pain moderate - severe pulsating, throbbing Duration4 hrs - 3 days Locationusually one sided (but side can swap between attacks) Symptomsaura nausea, vomiting sensitive to light, sound, smells

12. Typical migraine patient • onset often as child / teenager / young adult • but can start at any age • 2-3 x more common in women than men • typical patient : young woman (15% of all young women)

13. What happens during a migraine?

14. Migraine cause • cause unknown but strongly inherited • a lower threshold to spontaneously produce symptoms as if the head and brain had been injured • many effective treatments

15. Triggers • foods : spices, wine , chocolate, citrus • food additives : monosodium glutamate • sleep : both too much and too little • stress : mainly offset • female hormones : fluctuating or falling oestrogen

16. Migrainous Aura

17. Migrainous Aura

18. Migrainous Aura

19. Medication overuse headache • headache made WORSE by pain killers • only occurs in people who already had headache • mainly due to codeine-containing medicines or stronger morphine-like drugs • need to stop responsible medicines : easier said than done • we are trialling a new treatment for this

20. Frequency clusters – every time each year or season; then free Pain excruciating penetrating, boring continuous, non-throbbing Duration15mins-3 hrs; same clock time each day (2am); several episodes / day LocationALWAYS the same side Symptomswatering eyes nasal stuffiness, runny nose red eye, swollen eyelids sweating Cluster Headache Typical patient : middle aged male smoker

21. Cluster Headache

22. Trigeminal Neuralgia • VERY short (<1 sec) severe pain • Knife-like • Local triggering : eating etc Typical patient : middle aged / elderly woman

23. Other headaches • Paroxysmal hemicrania • “SUNCT” • short lasting neuralgiform;conjunctival injection, tearing • Stabbing headaches • After head injury / head surgery • Sexual headaches • Altitude sickness

24. Treatment Explanation, set realistic objectives Treatment of the attack Treatment to reduce attack frequency Lifestyle change

25. Treatment of the attack • General pain relievers • Migraine-specific treatments - triptans and ergots • Cluster specific treatment - oxygen - triptans

26. General pain relievers : migraine, tension Additives : metoclopramide (nausea) caffeine Not suitable : dextropropoxyphene “Doloxene; Di-Gesic” morphine, pethidine

27. Triptans : Imigran, Zomig, Naramig, Maxalt, Relpax FOR • can be very effective : migraine, cluster (NOT tension) • tablets, wafers, nasal spray, injection • AGAINST • feel strange, chest pain • expensive, small supply • overuse makes headaches more frequent • constrict blood vessels

28. Ergots : migraine, cluster FOR • can be very effective when others fail • nasal spray, suppository injection • AGAINST • hard to get • overuse causes poor circulation and more headache • not for tension

29. Preventative drugs • “mixed bag” of drugs used for other conditions found to be effective in headache usually by chance • usually for high blood pressure, depression, epilepsy • all work in somebody ; none works in everybody • generally reduce frequency but do not change attacks • key to success : trial and error : persist • need to start at low dose and increase until effective or not tolerated • about 50 % of patients will get 50% or more reduction in attacks

30. Main migraine preventers

31. Tension preventers

32. Cluster preventers - balance of effectiveness and safety / tolerability

33. Non drug Herbal • feverfew – no • butterbur – possibly Manual therapies • physiotherapy – caution • acupuncture – no Electrical occipital nerve stimulation : possibly Closure of hole in heart - no

34. In the pipeline

35. In the pipeline • “vaccination” for migraine • new classes of drugs

36. Our research • we are trialling a non-drug electrical therapy for tension-type headache • we are trialling a completely new drug approach to medication overuse headache • we may be trialling new agents for migraine in the near future

37. http://www.adelaide.edu.au/painresearch/participate/