Migraines & Tension headache

Question 1

What is a migraine?

Answer 1

Migraine is the most common cause of episodic headache

=> associated with sensory sensitivity to light, sound or movement or with nausea & vomiting

=> spectrum of severity between individuals and between each attack

=> high impact with inability to function normally

=> headache frequency varies

Question 2

Who does migraine commonly affect?

Answer 2

Women > men 3:1

Onset <40yrs

Question 3

What is the underlying pathology in migraines?

Answer 3

Neurogenic basis => spreading cortical depression

=> wave of neuronal depolarisation followed by depressed activity slowly spreading anteriorly across cerebral cortex from the occipital region

=> activation of trigeminal pain neurones

Question 4

What is the diagnostic criteria for migraines?

Answer 4

Headache lasting 4h to 3days (untreated)

At least two of:
=> Unilateral pain 
=> Throbbing type pain 
=> Moderate to severe intensity 
=> Motion sensitivity (headache made worse with movement)

At least one of:
=> Nausea/vomiting
=> Photophobia/phonophobia
=> Normal exam & no other causes of migraines

Question 5

Migraine without aura

i. Who does it affect?
ii. What is the clinical presentation?
iii. What are its triggers?

Answer 5

i. Starts around puberty

ii. Severe enough to prevent daily activity
=> Sleep helps
=> Allodynia (pain with all stimuli i.e. hurts to brush hair)
=> Prefer to be in dark, quiet environment

iii. Triggers:

=> sleep (too little/too much)

=> stress

=> hormonal factors i.e. with changing oestrogen levels during periods / with oral contraception

=> Skipping meals

=> Sensory stimuli i.e. bright lights, loud sounds, physical exertion, weather changes

Question 6

What is migraine with an aura?

Answer 6

25% of migraines with aura => focal neurological symptoms immediately preceding unilateral, throbbing headaches

=> aura evolves over 5-20mins with symptoms changing as the wave spreading neuronal depression moves across the cortex

=> doesn’t last longer than 60 mins

Question 7

What are the types of aura?

Answer 7

Types of aura:

=> Visual aura - most common i.e. shimmering, teichopsia (zigzag lines), fragmentation of image, scotomata or hemianopia

=> Somatosensory symptoms - mainly parasthesia spreading from fingers to face

=> Rare loss of motor function i.e. dysarthria, ataxia (basilar migraine)

=> Speech i.e. dysphagia, paraphasia (jumbled, meaningless words)

=> Opthalmoplegia

=> Hemiparesis

Question 8

What are partial triggers of migraines?

Answer 8

CHOCOLATE

C = chocolate

H = hangovers

O = orgasms

C = cheese, caffeine

O = oral contraceptives

L = lie-ins

A = alcohol

T = travel

E = exercise

=> these triggers seen in 50% of cases

Question 9

Which factors are associated with migraines?

Answer 9

Obesity

Family Hx

Question 10

What are the differentials for migraines?

Answer 10

Cluster or tension headache

Cervical spondylosis

Hypertension

Intracranial pathology

Sinusitus/otitis media

Dental caries

TIA may mimic migraine aura

Question 11

What is the prophylaxis treatment for migraines?

Answer 11

Avoid identified trigger

Prophylactic treatment:

=> Propranolol (1st line)

=> Topiramate (anti-convulsants + teratogenic)

=> Amitriptyline (tricyclics)

Can reduce headache frequency & severity by 50%

Question 12

What is the treatment during an attack?

Answer 12

Treatment during an attack:

=> Oral triptan (5-HT agonists) i.e. sumatriptan combined with NSAID or paracetamol

=> Anti-emetics i.e. metoclopramide if needed

Triptans are contraindicated in ischaemic heart disease, coronary spasm, uncontrolled BP, recent SSRI, lithium use

Question 13

What is the non-pharmaceutical management for migraines?

Answer 13

Warm or cold packs to the head

Rebreathing into paper bag

10 sessions of acupuncture over 5-8 weeks if both topiramate and propranolol unsuitable or ineffective

Transcutaneous nerve stimulation

Question 14

Considerations in Women:

1. Incidence of migraine with aura + ischaemic stroke is increased if using combined oral contraceptive pill

=> Use progesterone only pill or non-hormonal contraception in migraine with aura

=> Risk of migraine with aura + IHD further increased by 
smoking, 
>35yrs, hypertension, 
obesity, diabetes, hyperlipidaemia, 
family hx of arteriopathy <45yrs

=> Warn patients to stop OCP if migraines worsening or develop aura

Answer 14

INFO CARD

Question 15

Tension headache is a primary headache.

What are the characteristics of tension type headache?

Answer 15

Mild to moderate pain

Bilateral

Tight band sensation

Pressure behind eyes

Depression = frequent co-morbidity

Question 16

How do you treat tension headache?

Answer 16

Simple analgesics
=> avoid overuse as can lead to analgesic rebound headache

Massage, ice packs or relaxation helps

Question 17

Differentiation:

1. Tight band, bilateral, non-pulsatile ± scalp tenderness = Tension headache
2. Throbbing, pulsatile, unilateral = Migraine
3. Chronic progressive headache, worse on waking, lying, bending forward or coughing = Increased intracranial pressure
4. Episodic headache becoming chronic daily headaches = Analgesic rebound headache
5. Rapid onset of excruciating unilateral eye pain, watery and bloodshot, swollen lid, lacrimation, facial flushing, once to twice a day for 4-12 weeks = Cluster headaches

Answer 17

Differentiation:

1. Rapid onset, thunder-clap headache = Subarachnoid haemorrhage
2. Rapid onset, fever, photophobia, stiff neck, purpuric rash, coma = Meningitis
3. Rapid onset, fever, odd behaviour, fits, reduced consciousness = Encephalitis
4. Jaw claudication tender with thickened pulseless temporal arteries, sub-acute onset with raised ESR = giant cell arteritis

Question 18

Primary headaches:

Migraines

Tension headache

Cluster headache

Primary stabbing headache

Primary cough headache

Primary sex headache

Answer 18

Secondary headaches:

Raised intracranial pressure headache

Idiopathic intracranial hypertension

Low CSF volume headache

Post traumatic headache