Just a headache? Disentangling Headache and Facial Pain Dr Nicholas Silver Consultant Neurologist The Walton Centre for Neurology and Neurosurgery Liverpool.

““Just a headache?”Just a headache?”Disentangling Headache and Facial PainDisentangling Headache and Facial Pain

Dr Nicholas SilverDr Nicholas Silver

Consultant NeurologistConsultant Neurologist

The Walton Centre for Neurology and NeurosurgeryThe Walton Centre for Neurology and Neurosurgery

LiverpoolLiverpool

July 2008July 2008

OutlineOutline

BackgroundBackground

Red Flags and “secondary” headachesRed Flags and “secondary” headaches

The main primary headache disordersThe main primary headache disorders

Rarer and unusual primary headache Rarer and unusual primary headache disordersdisorders

Migraine and its many disguisesMigraine and its many disguises

Learning AimsLearning Aims

Necessity of Necessity of detaileddetailed and and directeddirected history historyRed flagsRed flagsDistinguish main primary headache disordersDistinguish main primary headache disordersRecognise migraine as by far the commonest Recognise migraine as by far the commonest presentation to hospital with headachepresentation to hospital with headacheRecognise non-headache manifestations of migraineRecognise non-headache manifestations of migraineTreatment of migraine and other headache disorders Treatment of migraine and other headache disorders

For copy of slides: e-mail For copy of slides: e-mail [email protected]

BackgroundBackground

““A Needle in a Haystack” A Needle in a Haystack” Primary Headaches are Very CommonPrimary Headaches are Very Common

A common symptom:A common symptom:– 10% of patients see GP’s each year with headaches10% of patients see GP’s each year with headaches

– 45% of general neurology consults to Walton Centre45% of general neurology consults to Walton Centre

Lifetime prevalence of headache:Lifetime prevalence of headache:– M: 93% (8% migraine, 69% tension type) M: 93% (8% migraine, 69% tension type)

– F : 99% (25% migraine, 88% tension type)F : 99% (25% migraine, 88% tension type)

Population-based studies:Population-based studies:– 4-5% of population fulfil criteria for 14-5% of population fulfil criteria for 100 chronic daily headache chronic daily headache

– 0.5% have severe 0.5% have severe dailydaily headaches headaches

The importance of headacheThe importance of headache

Headache as an indicator of diseaseHeadache as an indicator of disease

Invisible and disablingInvisible and disabling– World Health OrganisationWorld Health Organisation

Most common presenting neurological symptomMost common presenting neurological symptom

Socioeconomic costSocioeconomic cost

Easy to treatEasy to treat

Often poorly managedOften poorly managed

Presentation to hospital with headachePresentation to hospital with headache

Primary headaches outnumber secondary headachesPrimary headaches outnumber secondary headaches

Tension type headache hardly ever seen Tension type headache hardly ever seen – A A featurelessfeatureless headache that by definition is headache that by definition is nevernever severe severe

Chronic Migraine (+/- medication overuse) is extremely Chronic Migraine (+/- medication overuse) is extremely commoncommon– > 95% of my DGH ward and clinic referrals> 95% of my DGH ward and clinic referrals– Often poor history leads to wrong diagnosis of acute migraineOften poor history leads to wrong diagnosis of acute migraine– Acute migraine treatments will exacerbateAcute migraine treatments will exacerbate– Associated symptoms poorly recognisedAssociated symptoms poorly recognised– Often overinvestigated or referred to wrong specialistsOften overinvestigated or referred to wrong specialists

Trigeminal Autonomic Cephalgias are rareTrigeminal Autonomic Cephalgias are rare– Cluster headache is overdiagnosedCluster headache is overdiagnosed

Headache or facial painHeadache or facial pain

V nerveV nerve

? Migraine commonest cause of facial pain? Migraine commonest cause of facial pain

Misdiagnosis rate highMisdiagnosis rate high– Sinusitis Sinusitis – Eye disorderEye disorder– Tooth disorderTooth disorder– TMJ TMJ

Part 1Part 1Secondary HeadachesSecondary Headaches

““For most secondary headaches, the features of the For most secondary headaches, the features of the headache itself are poorly described in the scientific headache itself are poorly described in the scientific literature”literature”

““Even for those where it is well described, there are Even for those where it is well described, there are usually few diagnostically important features”usually few diagnostically important features”

The International Classification of Headache Disorders 2nd Edition, 2004The International Classification of Headache Disorders 2nd Edition, 2004

Secondary HeadachesSecondary Headaches

DiagnosedDiagnosed– Not by the type of headache, butNot by the type of headache, but

1.1. By the additional featuresBy the additional features

2.2. By the neurological symptoms and signsBy the neurological symptoms and signs

3.3. By looking at the whole patientBy looking at the whole patientImportance of systemic and endocrine enquiryImportance of systemic and endocrine enquiry

Importance of general medical examinationImportance of general medical examination

4.4. By vigilance, experience, methodical approach, By vigilance, experience, methodical approach, sixth sense and luck!sixth sense and luck!

““Red Flags”Red Flags”Raised ICP:Raised ICP:– Headaches: night > dayHeadaches: night > day

– OftenOften waking with waking with

headaches headaches ++ vomiting vomiting

– Relief on getting upRelief on getting up

– Clear Clear posturalpostural headache headache

– HA increased by HA increased by

ValsalvaValsalva

CoughCough

Bending forwardBending forward

– Visual ObscurationsVisual Obscurations

– Pulsatile TinnitusPulsatile Tinnitus

Low ICP Low ICP

– Fully disappears if flat Fully disappears if flat

(<30 mins)(<30 mins)

– May have sudden onset (e.g. May have sudden onset (e.g.

speed bump; fairground; LP)speed bump; fairground; LP)

““Red Flags”Red Flags”

Change in Headache PatternChange in Headache Pattern

New onset headache after 50yrsNew onset headache after 50yrs

Focal neurological Focal neurological signssigns

Acute confusionAcute confusion

Papilloedema / absent SVPPapilloedema / absent SVP

SuddenSudden onset onset

New Daily Persistent Headache New Daily Persistent Headache

(onset over 1-3 days, usually clearly (onset over 1-3 days, usually clearly

recall day it started)recall day it started)

Other illness - cancer / HIVOther illness - cancer / HIV

Systemic symptomsSystemic symptoms

– feverfever

– nuchal nuchal rigidityrigidity

– weight loss, etc.weight loss, etc.

Features of GCAFeatures of GCA– Jaw claudicationJaw claudication

– Localised temporal tenderness Localised temporal tenderness

– Myalgia / stiffnessMyalgia / stiffness

– Unilateral visual lossUnilateral visual loss

– Reduced appetiteReduced appetite

– Consider in all older patientsConsider in all older patients

Some serious secondary headaches to Some serious secondary headaches to consider in young peopleconsider in young people

MeningitisMeningitisCerebral abscessCerebral abscessEncephalitisEncephalitisBrain tumourBrain tumourSubarachnoid haemorrhageSubarachnoid haemorrhageCerebral venous thrombosisCerebral venous thrombosis– eg on OCP, pregnant, sinus or middle ear diseaseeg on OCP, pregnant, sinus or middle ear disease

Arnold Chiari malformationArnold Chiari malformationPituitary adenomaPituitary adenoma

Scans for headacheScans for headache

TO SCANTO SCAN– Only 1 in 1,000 with headache >3/12 + no red flags have Only 1 in 1,000 with headache >3/12 + no red flags have

abnormal scanabnormal scan

OR NOT:OR NOT:– MRI is too sensitive: approx 3-4% abnormal MRI scan (e.g. MRI is too sensitive: approx 3-4% abnormal MRI scan (e.g.

aneurysm, AVM)aneurysm, AVM)– White matter hyperintensities are very common (what do they White matter hyperintensities are very common (what do they

mean?)mean?)– Risk of scans and need for Risk of scans and need for pre-scan counsellingpre-scan counselling

radiation & cancer risk for CTradiation & cancer risk for CTcontrast allergycontrast allergyimplications for future insurance policiesimplications for future insurance policies

Note:Note: – Plain CT is not sensitive enough to exclude metastasesPlain CT is not sensitive enough to exclude metastases– Scans are not a substitute for good history and examinationScans are not a substitute for good history and examination

Part 2Part 2Primary HeadachesPrimary Headaches

IHS ClassificationIHS ClassificationICHD-IIICHD-II

Part 1: Part 1: The primary headachesThe primary headaches– 1. Migraine1. Migraine– 2. Tension-type headache2. Tension-type headache– 3. Cluster headache and other trigeminal autonomic3. Cluster headache and other trigeminal autonomic

cephalgiascephalgias– 4. Other primary headaches4. Other primary headaches

Part 2: Part 2: The secondary headachesThe secondary headachesPart 3: Part 3: Cranial neuralgias, facial pain and Cranial neuralgias, facial pain and

other headachesother headaches

Tension type headacheTension type headache

Is it really the commonest headache Is it really the commonest headache disorder?disorder?

Ask the audience!Ask the audience!

Tension-type headacheTension-type headache

Never severeNever severe

FeaturelessFeatureless– No sensitivity to noise, light, smellNo sensitivity to noise, light, smell– No nauseaNo nausea– No throbbingNo throbbing– No worse with exertion / movementNo worse with exertion / movement

Case History 1Case History 1

24 year male24 year maleNew headaches – always L sideNew headaches – always L sideLast 30-40 minutesLast 30-40 minutesWake patient at 1am – severeWake patient at 1am – severeV restless - pacing around room, bangs head V restless - pacing around room, bangs head against wall, rocksagainst wall, rocksOccasional in day – start with blocked L nostril, Occasional in day – start with blocked L nostril, may get red or runny eyemay get red or runny eyeMay occur within 30 minutes of alcoholMay occur within 30 minutes of alcoholSH – smoker, MDMA, cocaineSH – smoker, MDMA, cocaine

Diagnosis? Diagnosis?

But…..But…..

Occasional identical attacks in day; notes Occasional identical attacks in day; notes preceded by 20 – 30 minutes of evolving preceded by 20 – 30 minutes of evolving cerescentic scotoma with zig-zagscerescentic scotoma with zig-zags

On enquiry, reports:On enquiry, reports:– NauseaNausea– PhotophobiaPhotophobia– phonophobiaphonophobia

Cluster HeadacheCluster Headache

Cluster HeadacheCluster HeadacheMale>>femaleMale>>femaleRestless++Restless++Severe++++Severe++++Autonomic features usualAutonomic features usualAttacks < 4 hrsAttacks < 4 hrsETOH: immediate triggerETOH: immediate trigger

Sidelocked in individual clusterSidelocked in individual cluster

Aura – 20%Aura – 20%Photophobia, phonophobiaPhotophobia, phonophobia

GTN challenge (3 sprays): GTN challenge (3 sprays): provokes within 90 mins in allprovokes within 90 mins in all

MigraineMigraineFemale > maleFemale > maleNeed to stay stillNeed to stay stillSevere++Severe++Autonomic features +/-Autonomic features +/-Attacks > 4 hoursAttacks > 4 hoursETOH: delayed triggerETOH: delayed trigger““undeserved hangovers”undeserved hangovers”May vary sideMay vary side

Aura – 20%Aura – 20%Photophobia, phonophobiaPhotophobia, phonophobia

GTN challenge (3 sprays): GTN challenge (3 sprays): may induce headache within may induce headache within hourshours

Investigations?Investigations?

Treatment?Treatment?

Investigation of cluster headacheInvestigation of cluster headache

MRI brain + pituitaryMRI brain + pituitary

?MR angiography?MR angiography

Pituitary function blood testsPituitary function blood tests

Case 4Case 4Management of Cluster HeadacheManagement of Cluster Headache

Acute attacks:Acute attacks:– 100% Oxygen100% Oxygen

Air ProductsAir Products

– S/C Sumatriptan 6mg S/C Sumatriptan 6mg up to 2 doses per dayup to 2 doses per day

– Nasal Zomig 5mg up Nasal Zomig 5mg up to 3 doses per dayto 3 doses per day

Preventatives:Preventatives:– Prednisolone 60mg, Prednisolone 60mg,

reducing each 3-5 days reducing each 3-5 days by 10mgby 10mg

– Verapamil Verapamil (start 120mg bd, increase (start 120mg bd, increase up to 960mg / day) – very up to 960mg / day) – very effective; must have ECG effective; must have ECG prior to each dose increase prior to each dose increase to ensure normal ECG axis, to ensure normal ECG axis, PR interval, and QRS PR interval, and QRS complexescomplexes

– [Methysergide, [Methysergide, topiramate, Epilim]topiramate, Epilim]

Case History 2Case History 2

37 year man37 year man

Recalls exact onset of headache whilst sitting at desk 18/12 agoRecalls exact onset of headache whilst sitting at desk 18/12 ago

Persistent fluctuating bilateral vertex / occipital headache Persistent fluctuating bilateral vertex / occipital headache

No headache-free days since onsetNo headache-free days since onset

““Boring” and “Pressure” - Moderate to severe intensityBoring” and “Pressure” - Moderate to severe intensity

Featureless:Featureless:– No exacerbation with exertion, climbing stairsNo exacerbation with exertion, climbing stairs

– No nausea, vomitingNo nausea, vomiting

– No photophobia, phonophobia, osmophobiaNo photophobia, phonophobia, osmophobia

– No autonomic featuresNo autonomic features

– No change with postureNo change with posture

Mild relief with cocodamol Mild relief with cocodamol

Diagnosis?Diagnosis?

Investigations?Investigations?

Treatment?Treatment?

New Daily Persistent Headache New Daily Persistent Headache (“tension-type” phenotype)(“tension-type” phenotype)

Onset over < 3/7; Onset over < 3/7; Often recall initial day of onset of headacheOften recall initial day of onset of headache““Migraine” or “tension type” phenotypeMigraine” or “tension type” phenotypePrimary or secondaryPrimary or secondaryInvestigate all to exclude primary cause:Investigate all to exclude primary cause:– MRI brain + Gd, MR pituitary / MRAMRI brain + Gd, MR pituitary / MRA– FBC, ESR+CRP, Prolactin, TFT (+/- IGF1), Ca, B12, folate, FBC, ESR+CRP, Prolactin, TFT (+/- IGF1), Ca, B12, folate,

biochemistry, autoantibody screenbiochemistry, autoantibody screen

Prognosis: variable – can be difficult to treatPrognosis: variable – can be difficult to treat

Rx: as for chronic migraine – eliminate caffeine and Rx: as for chronic migraine – eliminate caffeine and medication overuse firstmedication overuse first

Learning pointsLearning points

New Daily Persistent Headache requires investigationNew Daily Persistent Headache requires investigation

Tension-type headache (TTH) is overdiagnosed +++++Tension-type headache (TTH) is overdiagnosed +++++TTH is TTH is – RareRare– Never severeNever severe– FeaturelessFeatureless– Not exacerbated by movementNot exacerbated by movement– Rx by simple analgesiaRx by simple analgesia

Chronic TTH is Rx by stopping acute attack medication Chronic TTH is Rx by stopping acute attack medication and starting amitriptyline and starting amitriptyline

Case History - 3Case History - 3

54 year male54 year male

Evolving constant but fluctuating daily moderate unilateral Evolving constant but fluctuating daily moderate unilateral (“(“side-lockedside-locked”) head pain for 9/12”) head pain for 9/12

Boring ache above and around R earBoring ache above and around R ear

Phonophobia, photophobiaPhonophobia, photophobia

Conjunctival injection and nasal congestion Conjunctival injection and nasal congestion

Jabs and jolts of pain in parietal areaJabs and jolts of pain in parietal area

No response toNo response to– Acute attack medications: codeine, paracetamol, tramadol, Acute attack medications: codeine, paracetamol, tramadol,

ibuprofen, sumatriptanibuprofen, sumatriptan– Preventatives: pizotifen, propranalol, gabapentin, epilim or Preventatives: pizotifen, propranalol, gabapentin, epilim or

amitriptylineamitriptyline

Diagnosis?Diagnosis?

Investigation of choice?Investigation of choice?

Hemicrania ContinuaHemicrania ContinuaA rare, indometacin responsive headache disorder characterised by A rare, indometacin responsive headache disorder characterised by continuous moderately severe headache that varies in intensity, waxing and continuous moderately severe headache that varies in intensity, waxing and waning without disappearing completelywaning without disappearing completelyUsually unilateralUsually unilateralRarely alternates sides or bilateralRarely alternates sides or bilateralJabs and joltscommonJabs and joltscommonExacerbations of pain often associated with autonomic disturbanceExacerbations of pain often associated with autonomic disturbanceExacerbations of pain most commonly associated with restlessnessExacerbations of pain most commonly associated with restlessnessOften migrainous features: photophobia, phonophobia, nauseaOften migrainous features: photophobia, phonophobia, nauseaMay remit and relapse or be continuousMay remit and relapse or be continuousDiagnosis established by Diagnosis established by completecomplete indometacin response indometacin responseRare secondary cases describedRare secondary cases describedRx: Rx: – Indometacin 25-250mg daily (withdrawal each 4-6 months as may remit)Indometacin 25-250mg daily (withdrawal each 4-6 months as may remit)– Other NSAIDs - Other NSAIDs - ibuprofen, celecoxib, and naproxen, ibuprofen, celecoxib, and naproxen, – Tricyclic antidepressantsTricyclic antidepressants– TopiramateTopiramate

Learning pointsLearning points

Strictly unilateral pains should always make one consider Strictly unilateral pains should always make one consider a trigeminal autonomic cephalgiaa trigeminal autonomic cephalgia

Always consider indometacin-responsive headache Always consider indometacin-responsive headache syndromes where no treatment has any benefitsyndromes where no treatment has any benefit

Hemicrania Continua is diagnosed by a complete Hemicrania Continua is diagnosed by a complete response to indometacinresponse to indometacin

Other indometacin-responsive primary headache Other indometacin-responsive primary headache syndromes include:syndromes include:– Paroxysmal HemicraniaParoxysmal Hemicrania– Primary Cough HeadachePrimary Cough Headache– Benign Sex HeadacheBenign Sex Headache

Case History - 4Case History - 4

24 year lady24 year lady

Extremely severe pains for 8/12Extremely severe pains for 8/12

Last 5-20 secondsLast 5-20 seconds

Occurs up to 150 times / dayOccurs up to 150 times / day

Triggered by eating, brushing hair, touching face, talking, Triggered by eating, brushing hair, touching face, talking, washing and cold windwashing and cold wind

Above eye in V1Above eye in V1

““Side-locked”Side-locked”

No response to carbamazepine, amitriptyline or gabapentinNo response to carbamazepine, amitriptyline or gabapentin

Suicidal; worst pain in life++++++Suicidal; worst pain in life++++++

Diagnosis? Diagnosis?

Any other questions to ask?Any other questions to ask?

Autonomic disturbance with painAutonomic disturbance with pain– Red eyeRed eye– TearingTearing– Swelling of eyelidSwelling of eyelid

No refractory period No refractory period – Continued stimulus continues to provoke Continued stimulus continues to provoke

severe painsevere pain

SUNCTSUNCT

SUNCT = “Short-lived Unilateral Neuralgiform headache SUNCT = “Short-lived Unilateral Neuralgiform headache with conjunctival injection and tearing”with conjunctival injection and tearing”

Newly recognised conditionNewly recognised conditionShort pains, most often in VShort pains, most often in V11

Pains may last longer than trigeminal neuralgiaPains may last longer than trigeminal neuralgiaTrigeminal neuralgia is rare in VTrigeminal neuralgia is rare in V11

SUNCT has no refractory periodSUNCT has no refractory periodAutonomic features are prominentAutonomic features are prominentResponds to lamotrigineResponds to lamotriginePoor if any response to carbamazepine / gabapentin)Poor if any response to carbamazepine / gabapentin)

Chronic Migraine (+ Medication Overuse)Chronic Migraine (+ Medication Overuse)

3 types of headache usually seen: 3 types of headache usually seen: 1.1. Severe migraine attacksSevere migraine attacks2.2. Background fills in with milder migrainous Background fills in with milder migrainous

headaches (often misdiagnosed as TTH)headaches (often misdiagnosed as TTH)3.3. Primary stabbing headachesPrimary stabbing headaches

Migraine-associated symptomsMigraine-associated symptoms

Often associated medication and/or caffeine Often associated medication and/or caffeine overuse, leading to failed trials of preventative overuse, leading to failed trials of preventative medicationmedication

Learning pointsLearning points

Take a thorough historyTake a thorough history

Beware “typical” conditions with atypical Beware “typical” conditions with atypical treatment responsetreatment response

Any facial pain Any facial pain maymay cause autonomic cause autonomic disturbancedisturbance

Autonomic disturbance is not only seen Autonomic disturbance is not only seen with cluster headachewith cluster headache

Differential diagnosis of primary headacheDifferential diagnosis of primary headacheFrequencyFrequency DurationDuration LateralityLaterality

SeveritySeverity

Migrainous Migrainous ““features” features”

(aura, (aura, photophobia, photophobia, nausea etc)nausea etc)

AutonomicAutonomic Behaviour / Behaviour / characteristic characteristic featuresfeatures

Tension-Tension-type type headacheheadache

Daily to Daily to monthlymonthly

hrs - hrs - monthsmonths

BilateralBilateral

Never severeNever severe

NEVERNEVER

TTH is TTH is featurelessfeatureless

NEVERNEVER Never limits Never limits activityactivity

MigraineMigraine Daily to Daily to monthlymonthly

> 4 hours > 4 hours to daysto days

Unilateral or Unilateral or bilateralbilateral

+/- severe+/- severe

YesYes ++ Stay flat and Stay flat and stillstill

Hemicrania Hemicrania ContinuaContinua**

ContinuousContinuous ContinuouContinuouss

SidelockedSidelocked

+/- severe+/- severe

+/-+/- ++++ --

Cluster Cluster headacheheadache**

Clusters or Clusters or chronic:chronic:

1-4 / day1-4 / day

< 4hours < 4hours

~ 15–40 ~ 15–40 minsmins

SidelockedSidelocked

Usually Usually severe +severe +++++

+/-+/- ++++++ Restless Restless agitation, agitation, pacing, pacing, holding headholding head

Paroxysmal Paroxysmal HemicraniaHemicrania**

10 – 40 / 10 – 40 / dayday

~ 10–20 ~ 10–20 minsmins

SidelockedSidelocked

UsuallyUsually severe + severe +++++

+/-+/- ++++ --

SUNCTSUNCT**

* MRI / MRA * MRI / MRA recommendedrecommended

60 – 400 / 60 – 400 / dayday

~ < 2 ~ < 2 minutesminutes

SidelockedSidelocked

Severe +++Severe +++

+/-+/- ++++ VV11 distribution /distribution /

No refractory No refractory periodperiod

Treatment of primary headacheTreatment of primary headacheAcute AttacksAcute Attacks Preventative StrategiesPreventative Strategies

Tension-type headacheTension-type headache ParacetamolParacetamol

NSAIDNSAID

Stop all painkillers / caffeineStop all painkillers / caffeine

AmitriptylineAmitriptyline

MirtazepineMirtazepine

MigraineMigraine [Aspirin 900mg or paracetamol 1G] + [Aspirin 900mg or paracetamol 1G] + domperidonedomperidone

Triptan – generic oral 50mg or 100mg Triptan – generic oral 50mg or 100mg sumatriptan is cheapestsumatriptan is cheapest

Stop all painkillers / caffeineStop all painkillers / caffeine

Tricyclics, propranalol, epilim, Tricyclics, propranalol, epilim, topiramatetopiramate

Hemicrania ContinuaHemicrania Continua N/AN/A IndometacinIndometacin

Cluster headacheCluster headache Pure 100% O2, 12-14l/min, sealed Pure 100% O2, 12-14l/min, sealed rebreathing maskrebreathing mask

s/c imigran 6mg prn bds/c imigran 6mg prn bd

Nasal zomig 5mg prn tds Nasal zomig 5mg prn tds

Verapamil (off licence) – Verapamil (off licence) – slow increase to 960mg / day slow increase to 960mg / day with ECG monitoringwith ECG monitoring

Epilim, topiramate, GON Epilim, topiramate, GON BlockBlock

Paroxysmal HemicraniaParoxysmal Hemicrania N/AN/A IndometacinIndometacin

SUNCTSUNCT N/AN/A LamotrigineLamotrigine

Intravenous LidocaineIntravenous Lidocaine

Part 3Part 3

Rarer and unusual primary Rarer and unusual primary headache disordersheadache disorders

Primary Cough HeadachePrimary Cough Headache

Brief headache induced by:Brief headache induced by:– Cough, sneeze, etcCough, sneeze, etc– May be severeMay be severe

Diagnosed Diagnosed afterafter MRI brain scan to exclude MRI brain scan to exclude cause of posterior fossa crowdingcause of posterior fossa crowding

Rx: Therapeutic LP (50%), IndometacinRx: Therapeutic LP (50%), Indometacin

Benign Sex HeadacheBenign Sex Headache

Sudden headacheSudden headache

At climax or beforeAt climax or before

SevereSevere

Investigate for SAH – CT / CSF (xanthochromia)Investigate for SAH – CT / CSF (xanthochromia)

Rx – reassure, different positions, propranalol, Rx – reassure, different positions, propranalol, indometacinindometacin

Benign Exertional HeadacheBenign Exertional Headache

Similar to benign sex headache (BSH)Similar to benign sex headache (BSH)

Often occurs in those who also have BSHOften occurs in those who also have BSH

Occurs with weight-lifting etcOccurs with weight-lifting etc– NB migraine with exercise = far commonerNB migraine with exercise = far commoner

Rx as for BSHRx as for BSH

Case History 5Case History 5

42 year female42 year femaleFacial painFacial painBouts lasting 3-4 days; increasingly frequentBouts lasting 3-4 days; increasingly frequentRight cheek / upper teeth / jawRight cheek / upper teeth / jawRarely involves left faceRarely involves left faceThrobbing / exploding painThrobbing / exploding painFeels unwellFeels unwellMild rhinorrhoeaMild rhinorrhoeaMild puffiness around left face – intermittent swelling Mild puffiness around left face – intermittent swelling and numbnessand numbnessNausea, tired, neck ache and looks depressedNausea, tired, neck ache and looks depressed

Diagnosis – ideas??Diagnosis – ideas??

What to do next??What to do next??

More historyMore history

Attacks increasing in frequencyAttacks increasing in frequency

Gaps filling in with milder painGaps filling in with milder pain

May radiate behind eyes and to templesMay radiate behind eyes and to temples

Photophobia, phonophobiaPhotophobia, phonophobia

Alcohol-intolerant: increased pain next dayAlcohol-intolerant: increased pain next day

In past:In past:– Travel sickness, abdominal pains in Travel sickness, abdominal pains in

childhood, “sinusitis episodes often in teens”childhood, “sinusitis episodes often in teens”

Diagnosis?Diagnosis?

Important questionsImportant questions

Painkillers usedPainkillers used

Caffeine consumptionCaffeine consumption

Sleep disturbanceSleep disturbance– Restless legs?Restless legs?– Periodic limb movements?Periodic limb movements?– OSA?OSA?

Part 4Part 4

Migraine and its many Migraine and its many disguisesdisguises

Case 1Case 1

What is M.E.?What is M.E.?

21 year lady21 year lady

Referred for management of intermittent headacheReferred for management of intermittent headacheStudying GCSE’sStudying GCSE’s

Longstanding symptoms of “ME” (diagnosed age 13)Longstanding symptoms of “ME” (diagnosed age 13)– Severe disabilitySevere disability with fatigue & very poor exercise tolerance with fatigue & very poor exercise tolerance

– Neck and low back painNeck and low back pain– Dizzy spells – lightheaded with depersonalisationDizzy spells – lightheaded with depersonalisation– Dizzy +++ with Dizzy +++ with visual visual stimuli – road markings, escalatorsstimuli – road markings, escalators– Insomnia – wakes 3x between 2 and 6 amInsomnia – wakes 3x between 2 and 6 am– Irritable and emotional with low moodIrritable and emotional with low mood– Forgetful, word-finding …….difficulties, comes out with the wrong wormsForgetful, word-finding …….difficulties, comes out with the wrong worms

HeadachesHeadaches – severe headaches 1-2 per month, particularly week before periodsevere headaches 1-2 per month, particularly week before period– Mild headaches between – tight band around head, as if wearing a hatMild headaches between – tight band around head, as if wearing a hat

RxRx– Nurofen 2-3 tablets per dayNurofen 2-3 tablets per day

Questions:Questions:

1.1. What other information would you want to know about the What other information would you want to know about the headaches?headaches?

2.2. Is there a unifying diagnosis?Is there a unifying diagnosis?

3.3. Management?Management?

What other information would you want to know about the headaches?What other information would you want to know about the headaches?

Onset of headache? Onset of headache? – approx 13 years (mild and occasional)approx 13 years (mild and occasional)

How did headaches change?How did headaches change?– gradual increase frequency / severitygradual increase frequency / severity

How many actual How many actual headache-freeheadache-free days? days? – <1-2 per month<1-2 per month

Are there any other Are there any other featuresfeatures of the “hat” like headaches of the “hat” like headaches – mild movement exacerbation causes throbbingmild movement exacerbation causes throbbing

– Subtle phonophobia and photophobiaSubtle phonophobia and photophobia

– ++ very mild nausea very mild nausea

Any other symptomsAny other symptoms– Craves sweet foodsCraves sweet foods before bad headachesbefore bad headaches

Caffeine intake?Caffeine intake?– 2 cups of tea per day, occasional chocolate2 cups of tea per day, occasional chocolate

Is there a unifying diagnosis?Is there a unifying diagnosis?– Chronic migraineChronic migraine– ? Migraine-related fatigue? Migraine-related fatigue

TestsTests– All blood tests normalAll blood tests normal

Management?Management? 1.1. Stop Stop allall caffeine + caffeine + allall painkillers painkillers

2.2. Lifestyle Lifestyle 3L fluid / day, 3L fluid / day, avoid missing meals, avoid missing meals, set 9 hours in bed with same bedtime and no lie insset 9 hours in bed with same bedtime and no lie ins

3.3. Preventative: Dosulepin (dothiepin) 25mg 3 hours before bedPreventative: Dosulepin (dothiepin) 25mg 3 hours before bed increase by 25mg each 2/52 according to benefit and side effectsincrease by 25mg each 2/52 according to benefit and side effects

Reviewed at 3/12:Reviewed at 3/12:

Initial thoughts after first consultation:Initial thoughts after first consultation:– Mother told her that “she” had migraine, her daughter “definitely did not” Mother told her that “she” had migraine, her daughter “definitely did not”

and that my diagnosis was “ludicrous”and that my diagnosis was “ludicrous”

– Patient had initially been very sceptical and did not think anything other Patient had initially been very sceptical and did not think anything other than headaches might get betterthan headaches might get better

Carried out plan:Carried out plan:Taking only 25mg dothiepinTaking only 25mg dothiepin

1 “migraine” headache in 3/121 “migraine” headache in 3/12

Now Now completely completely headache free 28-29 days per monthheadache free 28-29 days per month

Outcome:Outcome:– Feels “Feels “brilliantbrilliant”, “”, “totally back to normaltotally back to normal but a bit unfitbut a bit unfit””– All associated symptoms All associated symptoms fully fully resolved: resolved:

Neck pain, back pain, mood change, concentration, emotionalism, insomnia, Neck pain, back pain, mood change, concentration, emotionalism, insomnia, visual vertigo, panic type symptomsvisual vertigo, panic type symptoms

Case 2Case 2

Mad as a hatter??Mad as a hatter??

26 year male hairdresser26 year male hairdresser

Referred by GP for second opinion Referred by GP for second opinion – 2 year history of 2 year history of

severe headachessevere headaches

Separate vivid visual hallucinations (most < 10 seconds)Separate vivid visual hallucinations (most < 10 seconds)

flushingflushing

dizzinessdizziness

nauseanausea

occasional pupillary dilatationoccasional pupillary dilatation

– ? Psychiatric, ? Organic brain syndrome? Psychiatric, ? Organic brain syndrome

– Managed locally as migraine – “mother not happy with diagnosis”Managed locally as migraine – “mother not happy with diagnosis”

Hallucinations:Hallucinations:

Train on a cycle pathTrain on a cycle path

Same train, outside his houseSame train, outside his house

Vivid images of children or objectsVivid images of children or objects

Church parapet rising up in hallChurch parapet rising up in hall

Stinky yellow gungeStinky yellow gunge

+/- followed by headache, fatigue, dizziness, vomiting

Saw GP 3 years ago with occasional episodes of “being Saw GP 3 years ago with occasional episodes of “being completely split in two”. GP “laughed at me”completely split in two”. GP “laughed at me”

Severe Headaches:Severe Headaches:Triggers: perfumes, hair perm products (osmophobia)Triggers: perfumes, hair perm products (osmophobia)

Premonitory features:Premonitory features:– Irritable, very agitated, confusion Irritable, very agitated, confusion ++ slurred speech slurred speech

Headache:Headache:– Bilateral throbbing pain with movement exacerbationBilateral throbbing pain with movement exacerbation– Photophobia, phonophobia, osmophobiaPhotophobia, phonophobia, osmophobia– Nausea and / or vomitingNausea and / or vomiting– ++ vertigo or lightheaded / depersonalisation vertigo or lightheaded / depersonalisation

Postdrome – 1-2 days (fatigue, fragile, scalp tenderness)Postdrome – 1-2 days (fatigue, fragile, scalp tenderness)

Headaches:Headaches:Gradual evolution with increasing attack frequency and severityGradual evolution with increasing attack frequency and severity

Mild Mild and and severesevere migrainous headaches migrainous headaches

Rare Rare complete complete headache free daysheadache free days

Rx: Rx: – 12-16 paracetamol and 4 nurofen plus / month12-16 paracetamol and 4 nurofen plus / month

Caffeine:Caffeine:– 2 cups of coffee per day2 cups of coffee per day

PMH PMH – Childhood abdominal pain + pallor (hours)Childhood abdominal pain + pallor (hours)

– Childhood cyclical vomiting Childhood cyclical vomiting

– Childhood travel sicknessChildhood travel sickness

Examination:Examination:

Normal mental state, systemic, and neurological examinationsNormal mental state, systemic, and neurological examinations

Diagnosis in clinic:Diagnosis in clinic:

Previous acute migraine without auraPrevious acute migraine without aura

Chronic MigraineChronic Migraine– Migraine vertigoMigraine vertigo– Migraine syncopeMigraine syncope

Alice in Wonderland SyndromeAlice in Wonderland Syndrome

Full and maintained recovery to headache / symptom free Full and maintained recovery to headache / symptom free with stopping painkillers and caffeine, regular food / fluids / with stopping painkillers and caffeine, regular food / fluids / sleepsleep

Case 3Case 3

““Driving her dizzy, Driving her dizzy,

driving me mad”!driving me mad”!

36 year community nurse – on long term sick leave36 year community nurse – on long term sick leave

18/12 history of severe vertigo18/12 history of severe vertigo

Triggers:Triggers:– Driving on straight roadsDriving on straight roads– Escalators (fallen)Escalators (fallen)– Supermarket aislesSupermarket aisles– Bright wallsBright walls

Had to stop driving, as couldn’t drive straight if prominent Had to stop driving, as couldn’t drive straight if prominent road markingsroad markings

S/B ENT – no cause found, ? non-organicS/B ENT – no cause found, ? non-organic

Neurological history in clinic:Neurological history in clinic:Mild pressure in head – most daysMild pressure in head – most days– Around ears and templesAround ears and temples– Very mild phonophobiaVery mild phonophobia– Mild movement exacerbation (may throb)Mild movement exacerbation (may throb)

Moderate Moderate undeserved undeserved “hangover” headaches every 1-2 “hangover” headaches every 1-2 months, especially if before period (e.g. after minimal alcohol)months, especially if before period (e.g. after minimal alcohol)

Wakes every hour between 2 and 6 a.m.Wakes every hour between 2 and 6 a.m.

Mild word finding difficulties / wrong wordsMild word finding difficulties / wrong words

Occasional sensation of water dripping down on scalpOccasional sensation of water dripping down on scalp

Travel sickness as childTravel sickness as child

No painkillersNo painkillers

2-3 tea, 1-2 coffee, 1-2 cans cola per day2-3 tea, 1-2 coffee, 1-2 cans cola per day

Examination normalExamination normal

Diagnosis:Diagnosis:

Chronic migraineChronic migraine

Migraine-related visual vertigoMigraine-related visual vertigo

TreatmentTreatment

Stop all caffeine / painkillersStop all caffeine / painkillers

Fluids, regular food and sleep – avoid lie insFluids, regular food and sleep – avoid lie ins

Dosulepin 25mg, increased 50mg at 2/52Dosulepin 25mg, increased 50mg at 2/52

Outcome at 6/12:Outcome at 6/12:

Dizziness completely disappeared for last 5/12Dizziness completely disappeared for last 5/12

No headachesNo headaches

Returned to workReturned to work

MigraineMigraine

My definition:My definition:

““A primary headache disorder characterised by A primary headache disorder characterised by central central

sensitisationsensitisation and various combinations of and various combinations of neurologicalneurological, ,

systemicsystemic, , andand autonomicautonomic featuresfeatures””

Migraine is a relevant and very Migraine is a relevant and very common cause of disabilitycommon cause of disability

Very common in young adultsVery common in young adults

10% of the UK population consult a doctor each year for 10% of the UK population consult a doctor each year for headacheheadache

Migraine is Migraine is usuallyusually invisible to othersinvisible to others

The The World Health OrganisationWorld Health Organisation ranks acute migraine ranks acute migraine as as one of the 4 most disabling / incapacitating afflictionsone of the 4 most disabling / incapacitating afflictions, , alongside dementia, psychosis and quadriplegiaalongside dementia, psychosis and quadriplegia

Acute MigraineAcute MigraineTriggersTriggers

– Sleep deprivation Sleep deprivation – Sleep excess (eg “saturday morning headaches”)Sleep excess (eg “saturday morning headaches”)– Missing mealsMissing meals– DehydrationDehydration– Alcohol (“deserved” or “undeserved” hangovers)Alcohol (“deserved” or “undeserved” hangovers)– Hormonal (eg premenstrual, menstrual, 1Hormonal (eg premenstrual, menstrual, 1stst trimester, trimester,

postpartum, menopause)postpartum, menopause)– Exercise Exercise – TravelTravel– Stress / after stressStress / after stress– Dietary (very rare - < 1-2%) – e.g. citrus fruit, cheeseDietary (very rare - < 1-2%) – e.g. citrus fruit, cheese

The 4 stages of acute migraineThe 4 stages of acute migraine

AuraAura

ProdromeProdrome PostdromePostdrome HeadacheHeadache

+ + AssociatedAssociated featuresfeatures

HoursHours Minutes Minutes Hours Usually 1-2 daysHours Usually 1-2 days to hoursto hours to daysto days

Acute Migraine – ProdromeAcute Migraine – Prodrome(premonitory features)*(premonitory features)*

Mental StateMental State NeurologicalNeurological GeneralGeneralFatigueFatigue

IrritabilityIrritability

Depressed moodDepressed mood

EuphoriaEuphoria

HyperactivityHyperactivity

RestlessnessRestlessness

DepersonalisationDepersonalisation

DerealisationDerealisation

YawningYawning

PhonophobiaPhonophobia

PhotophobiaPhotophobia

OsmophobiaOsmophobia

LightheadedLightheaded

Food cravingFood craving

DizzinessDizziness

Neck pain / Neck pain / stiffnessstiffness

AnorexiaAnorexia

Frequent micturitionFrequent micturition

DiarrhoeaDiarrhoea

*prodrome seen in about 60% of patients*prodrome seen in about 60% of patients

Migraine - AuraMigraine - Aura

Only present in 20% of migraineursOnly present in 20% of migraineurs

Symptoms usually “evolve” over timeSymptoms usually “evolve” over time– Most commonly 20-30 minutesMost commonly 20-30 minutes– May persist hours - monthsMay persist hours - months

Pathophysiology is Pathophysiology is not not vascular (eg vasoconstriction / dilatation):vascular (eg vasoconstriction / dilatation):– ““cortical spreading depression” cortical spreading depression”

May occur without headacheMay occur without headache– ““acephalalgic” migraineacephalalgic” migraine– More common in elderlyMore common in elderly

““A complex of focal neurological symptoms A complex of focal neurological symptoms (positive or negative phenomena) that (positive or negative phenomena) that precede or accompany an attack”precede or accompany an attack”

Migraine - AuraMigraine - Aura

VisualVisual

SensorySensory– unilateral or bilateralunilateral or bilateral– e.g. pins and needles slowly spreading up arm to face to lege.g. pins and needles slowly spreading up arm to face to leg

Motor Motor – WeaknessWeakness– Movement disordersMovement disorders

Dysphasia / acute confusional state / coma, etc.Dysphasia / acute confusional state / coma, etc.

What are What are migrainous migrainous features of features of headache ?headache ?

Throbbing / poundingThrobbing / pounding

Head, neck and / or faceHead, neck and / or face

Unilateral Unilateral oror bilateral bilateral

TendernessTenderness

Nausea +/- vomitingNausea +/- vomiting

Exacerbating / trigger Exacerbating / trigger factorsfactors– MovementMovement– Noise (photophobia)Noise (photophobia)– Light (phonophobia)Light (phonophobia)– Smell (osmophobia)Smell (osmophobia)

Relieving factorsRelieving factors– FlatFlat– StillStill– VomitVomit– SleepSleep

Non-headache symptoms Non-headache symptoms of acute migraineof acute migraine

Mental StateMental State NeurologicalNeurological GeneralGeneralDepressionDepression

AnxietyAnxiety

FatigueFatigue

IrritabilityIrritability

IncapacityIncapacity

ConfusionConfusion

Blurred visionBlurred vision

ParaesthesiaeParaesthesiae

Sensation of insectsSensation of insects

or water on scalpor water on scalp

VertigoVertigo

Acute confusionAcute confusion

Word-finding difficultyWord-finding difficulty

AutonomicAutonomic

HemiplegiaHemiplegia

ComaComa

LightheadednessLightheadedness

SyncopeSyncope

FlushingFlushing

Cold extremitiesCold extremities

Scalp / face oedemaScalp / face oedema

Hair lossHair loss

Neck stiffnessNeck stiffness

AnorexiaAnorexia

Nausea / vomitNausea / vomit

EructationEructation

DiarrhoeaDiarrhoea

PolyuriaPolyuria

Migraine Autonomic SymptomsMigraine Autonomic Symptoms

Approx 20% of migraineursApprox 20% of migraineurs

Localised facial disturbanceLocalised facial disturbanceConjunctival injection (“red eye”)Conjunctival injection (“red eye”)Lacrimation (“tearing”)Lacrimation (“tearing”)Eyelid swellingEyelid swellingPtosisPtosisNasal congestion / rhinorrhoea (less common)Nasal congestion / rhinorrhoea (less common)ObjectiveObjective scalp or facial swellling scalp or facial swelllingFlushing (may be unilateral)Flushing (may be unilateral)

““Migraine is the commonest cause of Migraine is the commonest cause of

facial autonomic disturbance”facial autonomic disturbance”

Migraine – postdromeMigraine – postdrome

Resolution often associated with:Resolution often associated with:FatigueFatigueFragilityFragilityScalp tendernessScalp tenderness

Treatment of acute migraineTreatment of acute migraine

Be certain that > 25-27 brilliantly crystal clear Be certain that > 25-27 brilliantly crystal clear headache-free days before prescribing acute headache-free days before prescribing acute attack drugsattack drugs

If previous acute attack drugs have failed, likely If previous acute attack drugs have failed, likely to have chronic migraine to have chronic migraine ++ medication/caffeine medication/caffeine overuseoveruse

Lifestyle: Lifestyle: – ?stop caffeine?stop caffeine– Good fluid intake, regular meals, regular to sleepGood fluid intake, regular meals, regular to sleep

Rules of acute attack drugsRules of acute attack drugs

Treat as soon as throbbing headache startsTreat as soon as throbbing headache starts

Early treatment works betterEarly treatment works better

But:But: do do notnot treat in aura, as drugs ineffective treat in aura, as drugs ineffective

Do Do not not keep using acute drugs in same attack if prolonged keep using acute drugs in same attack if prolonged beyond 2 days (drugs will perpetuate attack to status beyond 2 days (drugs will perpetuate attack to status migrainosus)migrainosus)

Beware that any headache with migrainous features may Beware that any headache with migrainous features may respond to triptans regardless of underlying cause (eg respond to triptans regardless of underlying cause (eg tumour, SAH)tumour, SAH)

Treatment of acute migraineTreatment of acute migraine

Fluids ++ at onsetFluids ++ at onset

Ensure no nausea (domperidone)Ensure no nausea (domperidone)

RestRest

Non-invasive Non-invasive – Cold packsCold packs– 4head4head– Menthol stripsMenthol strips– Massage – neck, temples, scalpMassage – neck, temples, scalp

Treatment of acute migraineTreatment of acute migraine

11stst line: line: – PainkillerPainkiller

Soluble aspirin 900mgSoluble aspirin 900mg

Naproxen 500mgNaproxen 500mg

ParacetamolParacetamol

++– Domperidone (aid absorption of painkiller / fluids)Domperidone (aid absorption of painkiller / fluids)

20mg oral QDS PRN if nausea20mg oral QDS PRN if nausea

30-60mg “PR” BD PRN if vomit30-60mg “PR” BD PRN if vomit

Avoid other anti-emetics that compound gastric stasis Avoid other anti-emetics that compound gastric stasis – Stemetil, buccastem, cyclizineStemetil, buccastem, cyclizine

Avoid metoclopramide in young peopleAvoid metoclopramide in young people– Risk of oculogyric crisisRisk of oculogyric crisis

Treatment of acute migraineTreatment of acute migraine

22ndnd line line– TriptansTriptans

Start with oralStart with oral– Eg sumatriptan 50mg, sumatriptan 100mg, Eg sumatriptan 50mg, sumatriptan 100mg,

If vomit, consider nasal sprayIf vomit, consider nasal spray– E.g. Zomig 5mg (head tipped forward)E.g. Zomig 5mg (head tipped forward)

If wakes already with headache, consider s/cIf wakes already with headache, consider s/c– E.g. Imigran 6mg s/cE.g. Imigran 6mg s/c

Status migrainosusStatus migrainosus

Continued attack for daysContinued attack for days– Treat with Treat with

1.1. Stop all painkillers / triptansStop all painkillers / triptans

2.2. Avoid caffeineAvoid caffeine

3.3. AntiemeticsAntiemetics

4.4. Hydrate+++Hydrate+++

5.5. +/- 3/7 course of prednisolone+/- 3/7 course of prednisolone

Women and migraineWomen and migraine

Relative risk of stroke if aura and OCPRelative risk of stroke if aura and OCP– DiscussDiscuss

– Not absolute contraindication but avoid if possibleNot absolute contraindication but avoid if possible

– If necessary, use low oestrogen doseIf necessary, use low oestrogen dose

– Consider POPConsider POP

Menstrual migraineMenstrual migraine

– Consider tri-packed low dose OCPConsider tri-packed low dose OCP

Migraine preventatives and OCPMigraine preventatives and OCP

Topiramate induces pill (minimal)Topiramate induces pill (minimal)– Therefore use higher dose COCP or POPTherefore use higher dose COCP or POP

Migraine preventatives and Migraine preventatives and pregnancypregnancy

Best to avoid if possibleBest to avoid if possible

Teratogenic:Teratogenic:– Topiramate (? Risk)Topiramate (? Risk)– Valproate (risk of fetal valproate syndrome)Valproate (risk of fetal valproate syndrome)

High risk of significant learning disability / low IQHigh risk of significant learning disability / low IQ

– Tricyclics – probably safe (dosulepin, amitript)Tricyclics – probably safe (dosulepin, amitript)– Beta-blockers – probably safeBeta-blockers – probably safe

Women and migraineWomen and migraine

HRT is OK in menopausal women with previous hx of HRT is OK in menopausal women with previous hx of aura as low dose replacementaura as low dose replacement

Note that worsening migraine may be presenting feature Note that worsening migraine may be presenting feature of menopause of menopause beforebefore LH / FSH changes seen in blood; LH / FSH changes seen in blood; HRT may be worthwhile as treatment of migraine in this HRT may be worthwhile as treatment of migraine in this instanceinstance

Migraine and stroke riskMigraine and stroke risk

Migraine with aura: Migraine with aura: v slight increased riskv slight increased risk

Migraine without aura:Migraine without aura: no increased riskno increased risk

Migraine with aura + smoking: Migraine with aura + smoking: approx 8x increase risk approx 8x increase risk (more if chronic (more if chronic

migraine)migraine)– Independent of amount smokedIndependent of amount smoked– Occasional cigarettes may be just as harmfulOccasional cigarettes may be just as harmful– Risk declines over 2 years back to non-smoker level if stopRisk declines over 2 years back to non-smoker level if stop

Chronic MigraineChronic Migraine

Chronic MigraineChronic Migraine

Gradual characteristic evolution from acute to chronic stateGradual characteristic evolution from acute to chronic state

1.1. FrequencyFrequency increases increases

2.2. SeveritySeverity can increase or decrease can increase or decrease

3.3. GapsGaps between severe attacks “ between severe attacks “fill infill in” with milder migrainous ” with milder migrainous headaches (bilateral > unilateral)headaches (bilateral > unilateral)

4.4. Acute attack medication loses efficacyAcute attack medication loses efficacy e.g. painkillers / triptanse.g. painkillers / triptans

5.5. Pervasive Pervasive non-headachenon-headache features features usually diminish / disappear on usually diminish / disappear on completecomplete headache-free days headache-free days

Frequent headaches with migrainous featuresFrequent headaches with migrainous features

++

< 15 days per month headache-free< 15 days per month headache-free

Features of Chronic MigraineFeatures of Chronic Migraine

3 types of headache usually seen:3 types of headache usually seen: 1.1. Incapacitating headaches (often typical of previous migraine)Incapacitating headaches (often typical of previous migraine)

2.2. Frequent background “pressure” or “band-like” headaches Frequent background “pressure” or “band-like” headaches with mild or subtle migrainous featureswith mild or subtle migrainous features

3.3. +/- Idiopathic stabbing headaches+/- Idiopathic stabbing headaches

Migraine-associated symptomsMigraine-associated symptoms

Often associated medication and/or caffeine overuse, leading to Often associated medication and/or caffeine overuse, leading to failed trials of preventative medicationfailed trials of preventative medication

Chronic migraine may occur in relative absence of headacheChronic migraine may occur in relative absence of headache

Medication OveruseMedication Overuse

? Main cause of lack of response to headache ? Main cause of lack of response to headache preventativespreventatives

All acute attack medications can cause All acute attack medications can cause medication overuse:medication overuse:

If co-morbid neck pain, back pain or If co-morbid neck pain, back pain or “fibromyalgia”, still worth stopping painkillers, “fibromyalgia”, still worth stopping painkillers, as central sensitisation may heighten other as central sensitisation may heighten other bodily pains. bodily pains.

Caffeine OveruseCaffeine Overuse

Not “proven”, but long recognised to cause Not “proven”, but long recognised to cause headaches, especially on withdrawalheadaches, especially on withdrawal

Caffeine regarded as acute attack medicationCaffeine regarded as acute attack medication

Often in combined analgesicsOften in combined analgesics

Mild headaches (e.g. regarded as TTH) almost Mild headaches (e.g. regarded as TTH) almost always disappear with complete elimination of always disappear with complete elimination of acute medication and caffeineacute medication and caffeine

Caffeine withdrawal - first line for treatment-Caffeine withdrawal - first line for treatment-resistant depressionresistant depression

““Tea and Coffee HeadachesTea and Coffee Headaches. –. – In the nervous, In the nervous, and often the gouty and rheumatic person, the use and often the gouty and rheumatic person, the use of tea and coffee will cause violent headaches. of tea and coffee will cause violent headaches. These luxuries of life should be discontinued for at These luxuries of life should be discontinued for at least one month. An extra strong cup of black least one month. An extra strong cup of black coffee, to be sure, will stop the headache for the coffee, to be sure, will stop the headache for the time being, but only adds fuel to the fire in the long time being, but only adds fuel to the fire in the long run. We would strongly advise anyone that has run. We would strongly advise anyone that has constant or periodical headaches, if he uses either constant or periodical headaches, if he uses either tea or coffee, and especially coffee, to leave them tea or coffee, and especially coffee, to leave them off entirely for three months. It may be the sole off entirely for three months. It may be the sole cause, and if caused by tea and coffee, there is no cause, and if caused by tea and coffee, there is no possibility of their cure by medicines while you possibility of their cure by medicines while you continue their use”continue their use”

Virtue’s Household Physician Virtue’s Household Physician – circa 1920– circa 1920

Chronic MigraineChronic MigraineTriggers and Perpetuating FeaturesTriggers and Perpetuating Features

An InheritedPredisposition:

A “genetic disorder”A “genetic disorder”

+/- Family history+/- Family history

Travel sicknessTravel sickness•ChildhoodChildhood•Adulthood – with readingAdulthood – with reading

+/- previous migraine+/- previous migraine

Migrainous hangoversMigrainous hangoversUndeserved hangoversUndeserved hangovers

Comorbid IBSComorbid IBS

Triggers:

HormonesHormones•PregnancyPregnancy•PostpartumPostpartum•OCPOCP•MenopauseMenopause

Viral infectionViral infectionHead injuryHead injurySystemic illnessSystemic illnessNeurological illnessNeurological illnessNeurosurgeryNeurosurgeryEmotional stressEmotional stressIdiopathicIdiopathic

Perpetuating Factors:

PainkillersPainkillers OpioidsOpioids ParacetamolParacetamol NSAIDSNSAIDS

Triptans / ErgotTriptans / Ergot

CaffeineCaffeine CoffeeCoffee TeaTea ColaCola ChocolateChocolate LucozadeLucozade

Pani

Chronic Migraine: Chronic Migraine: “More Than Just a Headache”“More Than Just a Headache”

CoathangerNeck Pain

Biological Disturbance:Insomnia, poor STM, word substitutions, irritability, emotionalism, depression, anhedonia

Fatigue

Migraine Vertigo;Visual Vertigo;

“Veering”

Reflex Syncope

+/-FrequentHeadache

Sensory Disturbance(unilateral / bilateral)

“Panic-Type Symptoms”Lightheaded, depersonalisationderealisation, P+N, tinnitus, mutehearing, blurred vision, etc. +/- panic

Restless Legs syndrome

Distortion ofReality /Perception

Autonomic symptoms

FatigueFatigue

Fatigue is common in chronic migraineFatigue is common in chronic migraine11::– 84% scored >3 on Fatigue Severity Scale (FSS) 84% scored >3 on Fatigue Severity Scale (FSS) 22

– 67% met CDC67% met CDC33 criteria for Chronic Fatigue Syndrome criteria for Chronic Fatigue Syndrome

Headache is commonly not volunteered by patients Headache is commonly not volunteered by patients when presenting with other complaints when presenting with other complaints

Chronic migraine should be considered in all patients Chronic migraine should be considered in all patients presenting with chronic fatiguepresenting with chronic fatigue

11Peres et al (Cephalagia 2002:22:720-724)Peres et al (Cephalagia 2002:22:720-724)22c.f. normal (<2.8), MS (5-6.5), depression (4.5), CFS c.f. normal (<2.8), MS (5-6.5), depression (4.5), CFS

(6.1)(6.1)33Center for Disease Control and PreventionCenter for Disease Control and Prevention

Migraine-related dizzinessMigraine-related dizziness

1.1. ““Panic type symptoms”Panic type symptoms”LightheadedLightheadedDepersonalisation / derealisationDepersonalisation / derealisationHot, sweaty, flushedHot, sweaty, flushedBlurred, dim, or spotty visionBlurred, dim, or spotty visionMute and buzzy hearingMute and buzzy hearing+/- panic+/- panic+/- situation-specific – hot, bright, noisy, crowded+/- situation-specific – hot, bright, noisy, crowded

2.2. Migraine vertigoMigraine vertigo3.3. Visual vertigoVisual vertigo4.4. Unexplained veeringUnexplained veering

Distortion of realityDistortion of reality as a as a manifestation of migrainemanifestation of migraine

– Visual aura Visual aura

– Teleopsia - “zoom” visionTeleopsia - “zoom” vision

– Surroundings may appear Surroundings may appear very big or very smallvery big or very small

– Body image disturbances Body image disturbances body parts appear large, body parts appear large, small, distorted, reduplicated small, distorted, reduplicated or absentor absent

– Entomopia – “Insect eye” - Entomopia – “Insect eye” - multiple copies of same multiple copies of same image in grid-like patternimage in grid-like pattern

– Corona phenomenaCorona phenomena

– HallucinationsHallucinationsVisualVisualAuditoryAuditoryOlfactoryOlfactoryGustatoryGustatoryTactileTactile

– Cognitive deficitCognitive deficitapraxia, agnosiaapraxia, agnosiaacute confusional stateacute confusional state

– Language disturbanceLanguage disturbance““foreign accent syndrome”foreign accent syndrome”

– Delusions Delusions

– Paranoid psychosisParanoid psychosis

Alice in Wonderland SyndromeAlice in Wonderland SyndromeLippman 1952: Certain Hallucinations peculiar to MigraineLippman 1952: Certain Hallucinations peculiar to Migraine

– 1 patient with left ear ballooning out 6 inches or more1 patient with left ear ballooning out 6 inches or more– Body split in 2 halves as if by vertical line, with right size twice the size of left.Body split in 2 halves as if by vertical line, with right size twice the size of left.

Syndrome named by Todd, 1955, in relation to migraine and epilepsy:Syndrome named by Todd, 1955, in relation to migraine and epilepsy:– Characterised by the core symptoms of body schema disturbances and by a number of Characterised by the core symptoms of body schema disturbances and by a number of

facultative symptoms, including depersonalisation, derealisation, visual illusions and illusory facultative symptoms, including depersonalisation, derealisation, visual illusions and illusory alterations in the passage of timealterations in the passage of time

Bizarre visual illusions and spatial distortionsBizarre visual illusions and spatial distortions– Macropsia – Macropsia – world appears larger than normal / subject appears smallerworld appears larger than normal / subject appears smaller– Micropsia – Micropsia – opposite of macropsiaopposite of macropsia– Metamorphosia - Metamorphosia - sensation of formed body distortionssensation of formed body distortions– Zoom vision (e.g. teleopsia - Zoom vision (e.g. teleopsia - visual illusion of images moving away)visual illusion of images moving away)– ? Parietal phenomena? Parietal phenomena

Sense of time speeding up or slowing downSense of time speeding up or slowing down

More commonly reported in childrenMore commonly reported in childrenOften occurs before the headache beginsOften occurs before the headache beginsUsually followed by headacheUsually followed by headache

Also reported to occur with infectious mononucleosis, complex partial seizures, and Also reported to occur with infectious mononucleosis, complex partial seizures, and drug ingestion.drug ingestion.

Corona phenomenaCorona phenomena

Visual hallucinations in hemianopic visual field and corona phenomenon.

Podoll and Robinson, Cephalagia 2001;21:712-717

Splitting of the body imageSplitting of the body image

Podoll and Robinson, Cephalagia 2002;22:62-65)

MacrosomatognosiaMacrosomatognosia

Macrosomatognosia of both hands and arms.

(Podoll and Robinson, Acta Neurolo Scand 2000;101:413-416)

MacrosomatognosiaMacrosomatognosia

Macrosomatognosia of head, neck, both arms and hands.

(Podoll and Robinson, Acta Neurolo Scand 2000;101:413-416)

MigraineMigraine“The Chameleon in the Neurology Clinic”“The Chameleon in the Neurology Clinic”

HeadacheHeadache

Dizziness and VertigoDizziness and Vertigo

BlackoutsBlackouts

Sensory disturbanceSensory disturbance

FatigueFatigue

InsomniaInsomnia

Panic Attacks (+/- panic)Panic Attacks (+/- panic)

Chronic PainChronic Pain

– Neck pain / BrachalgiaNeck pain / Brachalgia

– Facial painFacial pain

– ““Fibromyalgia”Fibromyalgia”

? MS? MS

? Epilepsy? Epilepsy

? NEAD? NEAD

? TIA? TIA

? Stroke? Stroke

Chronic Fatigue SyndromeChronic Fatigue Syndrome

““ME”ME”

? Conversion disorder? Conversion disorder

““Depression”Depression”

My approach to successful treatment of My approach to successful treatment of chronic migrainechronic migraine

1.1. Withdraw all acute attack medication / caffeineWithdraw all acute attack medication / caffeine 2.2. LifestyleLifestyle

– regular sleep times without lie ins or daytime sleepregular sleep times without lie ins or daytime sleep– good hydration (2 ½ to 3 litres)good hydration (2 ½ to 3 litres)– regular mealsregular meals

3.3. PreventativePreventative (6-12 months) (6-12 months)– Start 2-3 weeks after analgesic / caffeine withdrawalStart 2-3 weeks after analgesic / caffeine withdrawal

Other Measures:Other Measures:– Encourage regular Encourage regular exerciseexercise as patient recovers as patient recovers

– Ensure completely avoids Ensure completely avoids smokingsmoking if migraine with aura, significantly if migraine with aura, significantly increased stroke riskincreased stroke risk

– Avoid Avoid oestrogensoestrogens below 50 years if migraine below 50 years if migraine with aurawith aura, as increased , as increased stroke riskstroke risk

The “foundation”1. No painkillers2. No caffeine3. Good fluids4. Regular meals5. Regular sleep

My approach to successful treatment of My approach to successful treatment of chronic migrainechronic migraine

The withdrawal:The withdrawal:Warn of possible severe worsening for 1-2 weeksWarn of possible severe worsening for 1-2 weeksWorsening is a good sign and usually heralds reverse to acute migraineWorsening is a good sign and usually heralds reverse to acute migraineAdmit for in-patient detoxification if severe triptan overuse, suicidal ideationAdmit for in-patient detoxification if severe triptan overuse, suicidal ideation– May assist withdrawal with:May assist withdrawal with:

Fluids (+/- IV)Fluids (+/- IV)Oral / rectal domperidoneOral / rectal domperidone5/7 Naproxen 500mg 8am + 4pm5/7 Naproxen 500mg 8am + 4pmClonidine (if opiates ++)Clonidine (if opiates ++)IM ChlorpromazineIM ChlorpromazineIV DihydroergotamineIV DihydroergotamineSteroidsSteroids

Combined pain syndromes:Combined pain syndromes:Advise that other pains often eventually improve Advise that other pains often eventually improve offoff painkillers (especially painkillers (especially neck and back), due to cessation of central sensitisationneck and back), due to cessation of central sensitisationConsider other measures for other pains:Consider other measures for other pains:– Back pain – Pilates, Extensor stretch exercises, swimming, pain clinic – epidurals Back pain – Pilates, Extensor stretch exercises, swimming, pain clinic – epidurals

etcetc– Neck Pain – usually improves ++Neck Pain – usually improves ++– Arthritis – glucosamine, large joint revision etc.Arthritis – glucosamine, large joint revision etc.

Trial

Evaluation

Criteria

Study size

(Cited trial (n)*)

Study population

(ITT/completers)

Treatment period

(no. weeks)

Licensed for migraine

prophylaxis?

Topiramate1 568 ITT 26 Yes (tertiary care)

Propranolol1 568 ITT 26 Yes

Pizotifen2 30 ITT 6 Yes

Sodium valproate3 29 Completer 16 No

Amitriptyline4 100 Completer 8 No

1. Diener H-C et al. J Neurol 2004; 251: 943–950. 2. Osterman PO. Acta Neurol Scand 1977; 56: 17–28.3. Hering R, Kuritzky A. 1992; 12: 81–84. 4. Couch JR, Hassanein RS. 1979; 36: 695–699.

*Largest reported or most often cited double-blind, placebo-controlled trial

Migraine prevention: Treatment options

Evaluating migraine clinical trials

ITT = intent-to-treat

Preventative Drugs for MigrainePreventative Drugs for MigraineLicensedLicensed Unlicensed Unlicensed

Beta Blockers*Beta Blockers*– PropranalolPropranalol (best evidence for use) (best evidence for use)– Timolol, MetoprololTimolol, Metoprolol

Antiepileptic Drugs (AED)Antiepileptic Drugs (AED)– TopiramateTopiramate******

OthersOthers– ClonidineClonidine (antihistamine and serotonin (antihistamine and serotonin

antagonist) – of no proven efficacy antagonist) – of no proven efficacy (BNF states “Clonidine is not (BNF states “Clonidine is not recommended and may aggravate recommended and may aggravate depression and cause insomnia”) depression and cause insomnia”)

– PizotifenPizotifen - evidence for effectiveness - evidence for effectiveness is poor; adverse effects severely limit is poor; adverse effects severely limit use use

– MethysergideMethysergide*** – considered very *** – considered very effective but concerns about about effective but concerns about about ergot side effects (retroperitoneal ergot side effects (retroperitoneal fibrosis etc)fibrosis etc)

Beta BlockersBeta Blockers– AtenololAtenolol (not licensed, but commonly (not licensed, but commonly

used)used)– NadololNadolol

Tricyclic antidepressants**Tricyclic antidepressants**– AmitriptylineAmitriptyline (best studied) (best studied)– DosulepinDosulepin (commonly used; (commonly used;

potentially better tolerated)potentially better tolerated)

Antiepileptic Drugs (AED)Antiepileptic Drugs (AED)– Sodium ValproateSodium Valproate****– GabapentinGabapentin (limited evidence of (limited evidence of

efficacy – 1 study)efficacy – 1 study)

NeurolepticsNeuroleptics

AlternativeAlternative– Butterbur, coenzyme Q10, riboflavin, Butterbur, coenzyme Q10, riboflavin,

feverfewfeverfew

* Partial agonists unhelpful; ideal beta blocker is hydrophilic and cardioselective* Partial agonists unhelpful; ideal beta blocker is hydrophilic and cardioselective** Unlicensed, but recommended for use in BNF!** Unlicensed, but recommended for use in BNF!*** Hospital Supervision or Specialist Introduction only*** Hospital Supervision or Specialist Introduction only

Chronic Migraine - RxChronic Migraine - RxDosulepinDosulepin (or amitriptyline) (or amitriptyline)– Aim for dose causing dry mouth Aim for dose causing dry mouth

without persistent tiredness without persistent tiredness – Take approx 3 hours before bedTake approx 3 hours before bed– Aim initially for approx 1mg /kg – Aim initially for approx 1mg /kg –

sometimes helps to go highersometimes helps to go higher

Epilim ChronoEpilim Chrono– + Folic acid / contraception if fertile + Folic acid / contraception if fertile

femalefemale– Warn – side effects: weight gain, Warn – side effects: weight gain,

hair loss, tremorhair loss, tremor– Up to 1000mg bdUp to 1000mg bd

TopiramateTopiramate– P+N at higher doses (often settles)P+N at higher doses (often settles)– Fluids++ to avoid renal calculiFluids++ to avoid renal calculi• + Folic acid / contraception if fertile + Folic acid / contraception if fertile

female Weight loss may occur (< female Weight loss may occur (< 10% body weight)10% body weight)

– Aim for 50mg bd; some respond to Aim for 50mg bd; some respond to higher doses (< 250mg bd)higher doses (< 250mg bd)

ParoxetineParoxetine– ?avoid in children?avoid in children– Warn side-effects (dizzy, Warn side-effects (dizzy,

nausea, drowsy) typically last nausea, drowsy) typically last only 2/52only 2/52

– Probably best starting 10mg, Probably best starting 10mg, increase 20mg after 1/52increase 20mg after 1/52

Propranalol (Inderal LA)Propranalol (Inderal LA)– Avoid if depression Avoid if depression – Up to 320mgUp to 320mg

FlunarizineFlunarizine– Rx of hemiplegic migraine, Rx of hemiplegic migraine,

alternating hemiplegia of alternating hemiplegia of childhoodchildhood

– Helpful in resistant casesHelpful in resistant cases– s/e weight gain, sedation, s/e weight gain, sedation,

parkinsonismparkinsonism

GabapentinGabapentin– Not very effectiveNot very effective

Chronic Migraine - RxChronic Migraine - RxOlanzepineOlanzepine– Helpful if very resistant casesHelpful if very resistant cases– Some very positive experience Some very positive experience

in those resistant to all other in those resistant to all other drugs (in specialist clinics drugs (in specialist clinics only)only)

PizotifenPizotifen– Very poorly tolerated – weight Very poorly tolerated – weight

gain and sedationgain and sedation– If tolerated, works reasonablyIf tolerated, works reasonably– Rarely used in headache Rarely used in headache

clinicsclinics

MethysergideMethysergide– Safe <12mg if monitor and Safe <12mg if monitor and

drug holidaysdrug holidays

ClonidineClonidine– Licensed, but never been Licensed, but never been

shown to helpshown to help

Lamotrigine, verapamil, Lamotrigine, verapamil, carbamazepinecarbamazepine– Unlikely to work as migraine Unlikely to work as migraine

preventativespreventatives

AcupunctureAcupuncture– Real but clinically insignificant Real but clinically insignificant

benefitbenefit

PhysioPhysio– Helpful for short term relief only Helpful for short term relief only

(e.g. hours to days)(e.g. hours to days)

Occipital Nerve StimulatorOccipital Nerve Stimulator– ExperimentalExperimental

PFO ClosurePFO Closure – Poor evidencePoor evidence– Only “advocated” by some for Only “advocated” by some for

migraine + auramigraine + aura– No “good” trial dataNo “good” trial data

Common misdiagnosis of Common misdiagnosis of chronic migrainechronic migraine

Cervicogenic Headache - Cervicogenic Headache - ? Exists – probably, but very rare? Exists – probably, but very rare

Chronic Tension Type Headache Chronic Tension Type Headache – ? Overdiagnosed+++ – ? Overdiagnosed+++

(CTTH is (CTTH is never never severe or associated with “features”) severe or associated with “features”)

I have seen 3 cases in last 3 years!I have seen 3 cases in last 3 years!

Eye Strain – Eye Strain – headaches only when reading / computer etc.headaches only when reading / computer etc.

Dental HeadachesDental Headaches

– TMJ dysfunction - ? TMJ dysfunction - ? overdiagnosedoverdiagnosed

– Dental disease – ? Dental disease – ? overdiagnosedoverdiagnosed

Atypical facial pain - Migraine commonly causes pain down lower Atypical facial pain - Migraine commonly causes pain down lower

jaw, over saddle of nose, in teeth, or over maxillajaw, over saddle of nose, in teeth, or over maxilla

““Sinus headache” - Sinus headache” - >95% of cases are migrainous>95% of cases are migrainous

Hypertensive Headaches – Hypertensive Headaches – only if encephalopathyonly if encephalopathy

Learning points: Learning points:

If in doubt, diagnose migraine If in doubt, diagnose migraine

Migraine may present with isolated facial painMigraine may present with isolated facial painMigraine may occur without Migraine may occur without anyany pain pain

Migraine Migraine oftenoften misdiagnosed as: misdiagnosed as:– Atypical facial painAtypical facial pain– Trigeminal neuralgiaTrigeminal neuralgia– Sinusitis, TMJ dysfunctionSinusitis, TMJ dysfunction

Always ask about migraine where unexplained symptomsAlways ask about migraine where unexplained symptomsAlways ask about headache-free days to guide management and to Always ask about headache-free days to guide management and to help diagnose associated features as migrainoushelp diagnose associated features as migrainous– E.g. chronic fatigue, fibromyalgia, ME, cervical spondylosis and E.g. chronic fatigue, fibromyalgia, ME, cervical spondylosis and

depression would not disappear on headache-free days!depression would not disappear on headache-free days!

A response to triptans does not confirm migraine and exclude A response to triptans does not confirm migraine and exclude serious underlying pathologyserious underlying pathology

SummarySummary

Chronic Migraine accounts for more than 90% of Chronic Migraine accounts for more than 90% of referrals to a specialist headache clinicreferrals to a specialist headache clinicIt is frequently misdiagnosed in hospital and primary careIt is frequently misdiagnosed in hospital and primary careChronic Migraine is a treatable disorderChronic Migraine is a treatable disorderChronic migraine may present with features other than Chronic migraine may present with features other than headacheheadacheIt is highly worthwhile taking full migraine history in It is highly worthwhile taking full migraine history in patients presenting with unexplained neurological patients presenting with unexplained neurological symptomssymptomsChronic migraine is an invisible cause of significant Chronic migraine is an invisible cause of significant disabilitydisability

For copy of slides: e-mail For copy of slides: e-mail [email protected]

Useful websitesUseful websites

BASH:BASH:

The British Association for the Study of The British Association for the Study of Headache Headache

Management guidelinesManagement guidelines

www.bash.org.ukwww.bash.org.uk

IHS: International Headache SocietyIHS: International Headache Society

Current IHS diagnostic criteria 2004Current IHS diagnostic criteria 2004

www.i-h-s.orgwww.i-h-s.org

Prodigy: new revised information and patient Prodigy: new revised information and patient information sheets information sheets www.prodigy.nhs.ukwww.prodigy.nhs.uk

Appendix – PFO ClosureAppendix – PFO Closure

MIST Study:MIST Study:– Prospective double blind placebo-controlled study (n=147)Prospective double blind placebo-controlled study (n=147)– Patients had only failed 2 preventativesPatients had only failed 2 preventatives– Study of frequent but not chronic migraineStudy of frequent but not chronic migraine– Based on observation that closure of large right to left cardiac shunts Based on observation that closure of large right to left cardiac shunts

may abolish migrainemay abolish migraine– Studied Migraine with Aura (only 20% of patients with migraine Studied Migraine with Aura (only 20% of patients with migraine

experience aura, and only proportion of these have significant cardiac experience aura, and only proportion of these have significant cardiac shunts)shunts)

– Conclusion: Negative Primary Endpoint, not reaching 40% elimination of Conclusion: Negative Primary Endpoint, not reaching 40% elimination of migraine at 6 months migraine at 6 months

37% (PFO Closure) vs 17% (sham)37% (PFO Closure) vs 17% (sham)Complications included tamponade, pericardial effusion, retroperitoneal Complications included tamponade, pericardial effusion, retroperitoneal bleed, and atrial fibrillationbleed, and atrial fibrillationResults can Results can notnot be generalised to migraine without aura be generalised to migraine without auraNB short (6/12) follow up - impossible to conclude curative Rx for chronic NB short (6/12) follow up - impossible to conclude curative Rx for chronic diseasedisease

– BASH: “On the basis of the current evidence, the cost and risk of this BASH: “On the basis of the current evidence, the cost and risk of this intervention are not commensurate with the benefits received”.intervention are not commensurate with the benefits received”.

Appendix – Indometacin ChallengeAppendix – Indometacin Challenge

Diagnostic test and Rx for Hemicrania Continua and Paroxysmal Diagnostic test and Rx for Hemicrania Continua and Paroxysmal Hemicrania Hemicrania (protocol available as patient information sheet from Walton Centre)(protocol available as patient information sheet from Walton Centre)

25mg tds 2/725mg tds 2/750mg tds 2/750mg tds 2/775mg tds 2/775mg tds 2/7100mg mane, 75mg midday, 75mg nocte 2/52100mg mane, 75mg midday, 75mg nocte 2/52Always cover with PPI (eg omeprazole)Always cover with PPI (eg omeprazole)Stay on lowest dose once diagnosis established by Stay on lowest dose once diagnosis established by complete complete elimination of elimination of pain with Indometacinpain with Indometacin

If not tolerated and diagnosis uncertain, consider double-blind IM Indotest If not tolerated and diagnosis uncertain, consider double-blind IM Indotest – (protocol and patient info sheet available from Walton Centre Pharmacy)(protocol and patient info sheet available from Walton Centre Pharmacy)

If not tolerated for treatment, consider GON blocks, GON stimulator, other If not tolerated for treatment, consider GON blocks, GON stimulator, other anecdotal therapiesanecdotal therapies

Appendix – IHS CriteriaAppendix – IHS Criteria

IHS diagnostic criteria for migraine without auraIHS diagnostic criteria for migraine without auraA: at least five attacks fulfilling criteria B–D A: at least five attacks fulfilling criteria B–D B: headache attacks lasting 4–72 hours B: headache attacks lasting 4–72 hours C: headache has C: headache has >>2 of the following:2 of the following:

unilateral locationunilateral locationpulsating qualitypulsating qualitymoderate or severe pain intensitymoderate or severe pain intensityaggravation by/causing avoidance of routine aggravation by/causing avoidance of routine physical activity physical activity

D: during headache at least one of:D: during headache at least one of:nausea and/or vomitingnausea and/or vomitingphotophobia and phonophobia photophobia and phonophobia

E: not attributed to another disorder E: not attributed to another disorder

Use supplementary to normal enquiry practiceUse supplementary to normal enquiry practice