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GP Trainees-Headache

GP Trainees-Headache. 16 th September 2009 Lalitha Vaithianathar Cons. Neurologist, RDH. Headache. History Taking Headache Cases Clinical f’s and Mx of: - Migraine - Tension type h/a - Medication overuse h/a - Trigeminal Autonomic Cephalgias. Primary h/a (%)

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GP Trainees-Headache

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  1. GP Trainees-Headache 16th September 2009 Lalitha Vaithianathar Cons. Neurologist, RDH

  2. Headache • History Taking • Headache Cases • Clinical f’s and Mx of: - Migraine - Tension type h/a - Medication overuse h/a - Trigeminal Autonomic Cephalgias

  3. Primary h/a (%) Migraine 16 Tension type 69 Cluster 0.1 Idiopathic stabbing 2 Exertional 1 Secondary h/a (%) Systemic infection 63 Head injury 4 SAH <1 Vascular disorders 1 Brain tumour 0.1 Common causes of Headache (%) = prevalence

  4. PRIMARY Migraine Benign exertional/coital. h/a Cluster h/a SECONDARY SAH Cerebral venous sinus thrombosis Arterial dissection Meningoencephalitis Pituitary apoplexy Acute hydrocephalus Acute hypertension Spontaneous intracranial hypotension Sudden onset Headache

  5. History taking in h/a

  6. History taking in h/a • Age of onset • 1° h/a usually begins early in life (before age 30-40), de novo h/a after age 50 more likely 2° • Current symptomatic presentation-de novo or new h/a in known h/a sufferer • Frequency and Duration • most 1° h/a’s are part defined by attack freq and duration

  7. History taking in h/a • Onset tempo • “thunderclap” vs acute onset (mins-hrs) vs subacute progressive (ds-wks) • Timing-nocturnal, waking • Site, quality and character of h/a • Triggers, aggravating and relieving f’s e.g. valsalva, postural change, time of day

  8. History taking in h/a • Assoc. symptoms • premonitory, focal, n, v, photo/phono/osmophobia, mechanosenitivity, autonomic sx’s, systemic sx’s, assoc. behaviour • Drug Hx • previous and present Rx’s (acute and preventative) • Analgesic intake • Family and comorbid medical hx

  9. Migraine

  10. Migraine • Migraine Without Aura- common type (80-90%) • Migraine With Aura -classic type (10-20%) • Subtypes: • Vertebrobasilar • Hemiplegic

  11. Migraine without aura • 5 attacks • 4h-72hrs • H/a character (at least 2 features) -unilateral -throbbing/pulsating -mod/severe -worse with physical activity • Assoc. symptoms (at least 1 feature) • Nausea and/or vomiting • Photophobia and phonophobia

  12. Migraine with aura • >1 attack • Typical features migraine without aura • Plus at least 3 of the following: • Fully reversible focal br.stem or cortical dysfunction • visual d including positive f’s (e.g. flickering lights, spots or lines) and/or negative f’s (loss of vision-scotoma, hemianopia, tunnel vision) • Sensory d of face/arm including positive f’s (e.g. p+n) and/or negative f’s (e.g.numbness) • Speech d-dysphasia - Aura develops over >4 mins, may change type during the attack - Each aura < 60 mins - Headache < 60 mins following aura

  13. Chronic Migraine • Migraine without aura, 15 or more days/mth for > 6 mths • No overuse of acute medication • Fulfills criteria for migraine without aura (but not each attack) • In practice often entangled with overuse of analgesics and triptans and CTTH • Difficult to define in pure form

  14. Migraine-trigger f’s • Relief of stress (e.g. weekends, holidays) • Hormonal changes (menstrual, menopause) • Physical exertion (sport, sex, work) • Change of routine (missed meals, sleep) • Visual glare, vivid patterns • Weather and atmospheric pressure changes • Foods and alcoholic drinks

  15. Migraine Treatment BASH (British association for the study of headache) guidelines: • Rest, sleep if possible Acute rescue Rx : • Trial each Rx for at least 3 attacks • Based on recognition of attacks of different types/ severity can use different steps on Rx ladder • Acute Rx not to be taken regularly i.e. >2 days wk, risk medication overuse headache

  16. Migraine Treatment Acute rescue Rx : • Step 1: • Aspirin (600-900mg) or ibuprofen (400-600mg) dissolvable prep, taken early in attack. Paracetamol alone-little evidence. Avoid Opiates • Aspirin or NSAIDs with prokinetic anti-emetic e.g. domperidone (Alt, Prochlorperazine 3mg buccal tablet). MigraMax or Paramax • Step 2: • Rectal analgesic ± anti-emetic e.g. diclofenac 100mg/ domperidone 30mg suppositories • Step 3: • Specific anti-migraine drugs e.g. Tryptans, Ergotamine

  17. Migraine Treatment Acute rescue Rx : -Triptans (N.B. expensive, inter and intra patient variation of response, incomplete delayed benefit, recurrence of migraine, 10% overuse) • At least Mod severity attacks • Not during aura phase or before onset of pain • CI: uncontrolled HPn, at risk of cardiac ischaemia • Sumatriptan, Zolmitryptan, Rizatriptan (rapid onset), *Almotriptan, Naratryptan (slower onset, ?less recurrence), Frovatryptan (longer action) • Ergotamine useful for repeated relapse, as long duration of action (NB misuse potential) • Unlicensed options-high dose O2, parenteral steroids (dexa 4mg), parenteral diclofenac or phenothiazines (chlorpromazine 25-50mg)

  18. Migraine Treatment Prevention of migraine (4 attacks/mth) • 1st Line Drug Rx’s • B-Blockers: atenolol 25-100mg bd; propranolol LA 80-160mg bd, • Amitryptiline (10-150mg) 1st line if migraine co-exists with Tension type h/a, other chronic pain conditions, disturbed sleep or depression • 2nd Line Drug Rx’s • Topiramate 25mg od- 50mg bd • Na Valproate 300-1000mg bd • 3rd Line Drug Rx’s • Gabapentin 300mg od – 800mg tds • Methysergide 1-2mg tds • B-Blockers with Amitryptilline • Flunarizine • Limited/uncertain efficacy: Pizotifen, Verapamil • If effective, continue for 4-6 mths • Hormone related migraine-keep diary (oestrogen withdrawel triggers migraine in some women)

  19. Tension type h/a

  20. Tension type h/a • “Featureless h/a” • At least 2 of the following: • Mild or mod intensity • Bilateral pain • Pressing/tight quality • No aggravation by simple physical activity • No nausea /vomiting; may have photo or phonophobia (not both) • Episodic (Attacks last 30 mins –7 days) or Chronic (>15 d/mth, for > 6 mths) • stress-related or assoc with functional or structural cervical/cranial musculoskeletal abnormality

  21. Tension type h/a • Treatment • Exercise, physio, lifestyle changes, relaxation/cognitive therapy, yoga/meditation • Episodic TTH: NSAIDS, paracetamol, avoid codeine • Chronic TTH: Amitryptilline (75-150mg/d). Dothiepin. Cognitive therapies, TENS, acupuncture

  22. Medication overuse h/a • Common complicating issue in chronic daily h/a (typically pts with migraine or TTH) • Use of an acute attack Rx > 2d/wk regularly, usually with dose escalation over time • Compound OTC analgesics with combinations of paracetamol or aspirin, caffeine or codeine phosphate, or both; Triptans; • Rx: medication withdrawel • try naproxen 250-500mg bd for 3/52 as one off (may break cycle)

  23. Trigeminal autonomic cephalgias

  24. Cluster h/a • Prevalence 0.1% • Male:female ratio approx 5:1 • Usually primary h/a disorder, occasl post-traumatic, or rarely secondary to pituitary tumour or aneurysm • Occasl familial cases 4-7% • Majority heavy smokers • Onset typically age 20-30 • Triggers: alcohol (within 1hr), nitroglycerine, exercise, warm room

  25. Cluster h/a • Severe unilateral orbital, supraorbital, temporal pain lasting 15 mins-3hrs (rapid onset and cessation), boring or stabbing in nature • Freq 1-8/d (circadian periodicity) • Assoc with 1 of: • Lacrimation • Conjunctival injection • Nasal congestion • Rhinorrhoea • Forehead/facial sweating • Ptosis • Meiosis • Eyelid oedema OR • Sense of restlessness or agitation during h/a • Nausea, vomiting and photophobia rare

  26. Cluster h/a Treatment • General measures e.g abstaining from alcohol during attacks • Abortive agents: Triptans (Sumatriptan s/c 6mg), Oxygen 100% 7-12l/min, intranasal lignocaine • Preventative: • Short term: Steroids (Pred 60mg, tapering course 2-3/52); • Long term: Verapamil, Topiramate, Methysergide, Lithium

  27. Paroxysmal Hemicrania • V. rare, MRI advised as rel. high incidence symptomatic cases • Female:Male 2:1 • Episodic and chronic forms • Attacks shorter, more freqt than CH (upto 40/d) • Duration 2-45 mins • May be triggered by head/neck movement • v. severe orbital, fronto-temporal pain, ipsilateral cranial autonomic f’s, 50% show restlessness as in CH • Response to Indomethacin diagnostic

  28. Summary • Good history can distinguish between headache types • Headache management requires a flexible and individualised approach

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