W21 Headache and Migraine

Question 1

What are headaches categorised into?

Answer 1

• Categorised by International Classification of Headache Disorders (ICHD)
• Primary Headaches – not associated with underlying condition (most common)
  Migraine, Tension headache, cluster headache
• Secondary Headaches – Caused by underlying issue/condition
• Trauma/injury to head/neck area, intracranial haemorrhage, giant cell arteritis, stroke/TIA, brain malignancy
• Substance exposure, misuse/overuse, withdrawal
• Infection, glaucoma, psych. disorders, HTN

Question 2

Examples of primary headaches? (3)

Answer 2

• Primary Headaches – not associated with underlying condition (most common)
  Migraine, Tension headache, cluster headache

Question 3

Examples of causs of secondary headaches? (3)

Answer 3

• Secondary Headaches – Caused by underlying issue/condition
• Trauma/injury to head/neck area, intracranial haemorrhage, giant cell arteritis, stroke/TIA, brain malignancy
• Substance exposure, misuse/overuse, withdrawal
• Infection, glaucoma, psych. disorders, HTN

Question 4

How can you assess a headache?

Answer 4

• Identify RED FLAGS that suggest a serious secondary cause – for further specialist assessment
• Pain – Onset, duration, frequency, pattern, location, severity, quality
• Associated symptoms – Aura, N&V, motion problems, photophobia, phonophobia
• Autonomic symptoms – Lacrimation, conjunctival injection, rhinorrhoea
• Precipitated or associated with a trigger?
• Comorbidity present?
• Medication taken for symptom relief?
• Symptoms relieved?
• Impact on daily activity/QoL?
• Examination – Vital signs, mental state, alertness, neck/face/intracranial structure, Neuro exam, fundoscopy
• Headache diary – Useful if primary diagnosis unclear but secondary cause ruled out – period of 8 weeks

Question 5

What is a Migraine?
with aura?

Answer 5

• Common Primary headache disorder
• Episodes of Moderate/Severe headache – unilateral mostly, pulsating or throbbing
• Associated with photophobia, phonophobia, N&V

Aura
-Sensation experienced before or during a migraine attack
-Visual aura – Blind spot, blurred vision, zigzag lines
-Sensory aura – Pins & needles

Question 6

2 types of migraine?
What are the triggers? (6)

Answer 6

• Episodic – attacks occur less than 15 days/month
• Chronic – attacks on at least 15 days per month for more than 3 months

Triggers:
Factors that can start an attack
Poor sleep
Irregular/missed meals
Excess caffeine
Menstruation
Stress

Question 7

What are the factors increasing risk of chronic migraine?

Answer 7

• High frequency of episodic migraine
• Overuse of medication to treat acute episodes
• Excess caffeine
• Obesity
• Snoring/sleep disorders
• Co-morbidity – head injury, pain disorder, anxiety, depression
• Life events – divorce, marriage, job loss

Question 8

Prevalence and Prognosis of migraine
(for info)

Answer 8

Prevalence;
1 in 7 sufferers globally
2-3 times more common in women
Most common in age 25-55years
Around 8% of migraine sufferers have chronic migraine

Prognosis;
Improves with age
Improves after menopause in women
Pregnancy improvement – reduced frequency or severity of attacks in trimesters 2&3

Question 9

Migraine without Aura Diagnosis:

Answer 9

At least 5 attacks of:
Headache lasting 4-72hours in Adults (2072hrs in adolescents)
Headache with at least 2 of:
Unilateral location, pulsating/throbbing/banging, moderate or sever pain, aggravated by or affects daily activities
Headache with nausea & vomiting, photophobia and phonophobia
Headache not accounted for by another diagnosis

Question 10

Migraine with aura diagnosis:
What are the conditions?
2 attacks of..?
3 of?

Answer 10

At least 2 attacks of:
1+ fully reversible aura sympom – Visual, sensory or speech

At least 3 of:
1+ aura symptom spreading over 5 mins
2+ aura symptoms in succession
Each aura symptom lasts 5-60 mins
At least one symptom is unilateral
At least one symptom is positive

Headache not accounted for by another diagnosis

Question 11

Atypical aura:
What are the non-regular aura symptoms? (5)

Answer 11

Motor weakness
Double vision
Visual symptoms in one eye only
Poor balance
Reduced consciousness

Admission or urgent specialist advice needed

Question 12

Aura with no headache:

Answer 12

• Attack of aura but without headache
• No headache makes it difficult to exclude other causes
• Further investigation needed

Question 13

What are
Prodromal symptoms?
Postdromal symptoms?
Menstrual related migraine?

Answer 13

Symptoms occur from 2 days up to hours before other migraine symptoms
-Fatigue, poor concentration, neck stiffness, yawning

Occur AFTER headache and can last up to 48 hours
-Fatigue, elation, depressed mood

Women or girls with migraine symptoms around the start of menstruation cycle for at least 2/3 cycles

Question 14

What is the differential diagnosis of Migraine?

Answer 14

Tension Headache
Cluster Headache
Paroxysmal Hemicrania
Cough/cold Headache
Trauma/injury to head/neck
Intracerebral Haemorrhage
Central Venous Thrombosis
Giant Cell Arteritis
TIA/Stroke
Idiopathic Intracranial Hypertension
Neoplasm
Substance Withdrawal
Medication Overuse
CO Exposure
Intracranial Infection
Hypoxia
Hypertension
Pre-eclampsia/Eclampsia
Closed Angle Glaucoma
Dental Problem
Otitis Media
Sinusitis
Somatisation Disorder

Question 15

Management of Migraine in Adults?

Answer 15

Advice/Self Care
Migraine Diary
Avoid Triggers
Lifestyle changes – Stress, sleep hygiene, hydration, regular meals, exercise, weight
Treat co-morbidities – Sleep apnoea, insomnia, depression & anxiety

Medication Overuse Headache (MOH)
- Restrict acute meds use to max. 2 days a week
Inc. risk if using simple analgesics >15 days/month or Triptans/combination analgesics for >10 days/month

Combined Hormonal Contraceptives – CI in women with migraine + aura

Question 16

Acute treatment of migraine? (3)
When to follow up?

Answer 16

• Simple analgesics ( NSAIDs, Aspirin, Paracetamol)
• Triptans(Sumatriptan, Naratriptan, Rizatriptan, Zolmitriptan)
• Anti-emetics (Prochloperazine, Metoclopramide)
• Acute medication should be started as early as possible at onset of pain or aura
• No ergots or opioids should be used
• Follow up in 2-8 weeks

Question 17

Migraines-
When to follow up?

Answer 17

• 2-8 weeks after starting treatment – sooner if headache changes or experiencing adverse effects of Tx
• Assess frequency of attacks, Tx effectiveness, adverse effects, lifestyle improvement
  Ctu Tx if effective, appropriate use and well tolerated

If Tx ineffective:
- Reconfirm diagnosis – Referral???
- Alternative Triptan or combine with an NSAID or Paracetamol
- Consider prophylactic therapy
Refer to specialist if migraine is of uncommon type

Question 18

Prophylactic Treatment of migraines:
What is the aim of treatment?
What are the treatment options?

Answer 18

Aim to reduce frequency, severity and duration of attacks & avoid MOH

When to consider:
- Attacks are impacting on QoL and daily activities
- Acute Tx is CI or ineffective
- Patient is at risk of MOH – rule out before starting, also manage suspected MOH with drug withdrawal

Treatment options:
Propranolol
Topiramate
Amitriptyline
Pizotifen
(DO NOT offer Gabapentin)
Non Pharm – Behavioural intervention, Acupuncture, Riboflavin

Question 19

Prophylactic Treatment

Answer 19

Consider CI, co-morbidities, risk of adverse effects
Discuss benefits and risks with patient
Topiramate - Teratogenic
discuss risk of foetal malformation
reduced effectiveness of hormonal contraceptives
importance of effective contraception
Initiate low dose and titrate according to efficacy and tolerability
Advise patient on rationale for prophylaxis and lifestyle advice
Follow up every 2-3 weeks to assess effectiveness, adverse effects and titrate dose
Advise on keeping headache diary, review sooner if anything changes, can take up to 8 weeks to notice any improvement
6-12 months after starting consider need to continue and gradually withdraw treatment

Question 20

Management of Migraine in 12-17 year olds:
- What to ask in hx taking?
- What meds to give? treatment?

Answer 20

History, examination, assessment:
* Causes/triggers
* Time off school/college
* General health
* Anxiety/concern?
* Headache diary

Management:
* Self care – avoid triggers, keep headache diary
* Simple analgesia for symptomatic relief – Paracetamol, Ibuprofen
* Nasal Triptan therapy if simple analgesia not effective – oral triptans not licensed in under 18s
* Follow up in 1 month
* Refer to sec. care if prophylactic treatment needed – should not be started in primary care

Question 21

Management of Migraine in Pregnancy & Breastfeeding

Answer 21

• Migraine may improve in trimester 2 and 3 of pregnancy
• Try non – pharm measures first – avoi triggers, relaxation, CBT
• Many treatments CI or limited evidence of safety
• Awareness of risks if drug therapy needed
• Paracetamol 1st line
• Ibuprofen or Triptan if ineffective (Sumatriptan preferred triptan)
• Avoid NSAID in trimester 3
• NO Aspirin or opiates
• Follow up in1 month – low threshold for sec. care referral
• Seek specialist advice if prophylactic treatment needed

Question 22

Triptans
What is their receptor target? MoA?
Examples?
First-line?
Not licensed in..?

Answer 22

• 5-HT1 receptor agonists -receptor activation causes cranial vessel vasoconstriction
• Sumatriptan, Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Zolmitriptan
• SIGN recommends Sumatriptan as 1st line option
  Try alternative if Sumatriptan ineffective
• Use non-oral formulation if vomiting restricts oral intake
  Nasal Spray
  Subcut. Injection
• Not licensed in over 65s

Question 23

Triptans
C/I?

Answer 23

Contraindications?
CV disorders
TIA/CVA
Severe Hepatic Impairment
Other triptans, MAOIs, Ergotamine

Cautions?
CVD Risk Factors
Elderly
Hx risk factors for seizures
Renal/Hepatic impairment – reduce dose

Counselling?
Take one dose at onset of symptoms
Take another dose if needed at least 2 hours later if migraine/symptoms recur
Max 2 doses in 24 hours

Side Effects?
Dizzyness/Drowsiness
Dyspnoea
Nausea, vomiting, dysphagia
Intestinal ischaemia
Myalgia
Flushing
Fatigue
Epistaxis, nasal irritation, altered taste and throat irritation (Nasal spray)

Question 24

Anti-emetics:
Examples?
C/I?
Cautions?

Answer 24

Metoclopramide & Prochlorperazine
* Metoclopramide used in nausea treatment in acute migraine but NOT LICENSED
* Metoclopramide not to be used regularly – risk of EPSE, short term use only
* Prochlorperazine buccal tablet for nausea & vomiting

Contraindications:
* GI haemorrhage, obstruction, perforation or recent surgery
* Phaeochromocytoma
* Parkinson’s Disease
* CNS depression
* Liver/Kidney dysfunction
* QT prolongation
* Heart Failure

Cautions:
* Children & young adults
* Renal & Hepatic impairment
* Cardiac disorders
* Elderly
* Hypothyroidism
* Renal impairment
* CV risk factors

Question 25

Triptans Drug interactions? P & BF?

Answer 25

Drug interactions: * MAOIs – plus 2 weeks after stopping * MAOI * CYP 3A4 inhibitors e.g Clarithromycin, Ketoconazole * Other Triptans – 24hr washout needed when switching * Other triptans, MAOIs, Ergotamine SSRIs & SNRIs * Lithium * Ondansetron * St John’s Wort – Risk of Serotonin Syndrome * Propranolol – Rizatriptan max. dose 5mg & not within 2hrs of each other Pregnancy * Limited data * Avoid unless benefit outweighs risk Breastfeeding: * Present in milk * Too small to be harmful * Minimise infant exposure * Avoid feeding for 12 hours after a dose * Express and discard any milk during those 12 hours

Question 26

Anti-emetics What are the side effects of Metoclopramide? (Same as Prochlorperazine)

Answer 26

Acute dystonias Diarrhoea Asthenia Drowsiness Depression Hypotension EPSE Drowsiness Blood disorders Endocrine disorders Insomnia Agitation Hyponatraemia SADH Skin reactions, cardiac dius

Question 27

Anti-emetics What are the side effects of Prochlorperazine?

Answer 27

* EPSE (parkinsonism, akinesia, dystonia, akathisia) * Drowsiness * Blood disorders * Endocrine disorders * Insomnia * Agitation * Hyponatraemia * SADH (syndrome of inappropriate antidiuretic hormone secretion) * Skin reactions * Cardiac disorders * Jaundice * Muscle rigidity * Nasal congestion * Respiratory depression * Neuroleptic malignant syndrome

Question 28

Anti-emetics: What are the interactions of Metoclopramide? (4)

Answer 28

* Levodopa/Dopamine agonists (apomorphine, ropinirole, rotigotine, pramipexole) * Alcohol * CNS depressants (TCA, SNRI, SSRI) * Serotinergics (SSRIs)

Question 29

What are the interactions of Prochlorperazine?

Answer 29

Alcohol Amitriptyline Antihypertensives CNS depressants Cabergoline, levodopa, ropinirole QT prolonging drugs Carbamazepine

Question 30

Anti-emetics in pregnancy and BF:

Answer 30

Pregnancy: Metoclopramide not known to be harmful But avoid at end of pregnancy due to potential EPSE in newborn depressants Avoid prochlorperazine unless benefit outweighs risk Reports of EPSE and withdrawal in neonates if taken during trimester 3 Breastfeeding: Avoid metoclopramide, small amounts in breast milk Avoid prochlorperazine – limited data but animal studies indicate adverse effects

Question 31

Propranolol Contraindications? Cautions? Side Effects? Drug interactions? P & BF?

Answer 31

Contraindications: Asthma & COPD Cardiovascular Cardiogenic shock Hypotension Bradycardia Heart lock Angina PVD Heart Failure Phaeochromocytoma Cautions: Diabetes Myasthenia gravis Hepatic & renal impairment Psoriasis Side Effects: Hypoglycaemia CNS – Dizziness, confusion etc Sleep disturbance, nightmares, depression Dry eye Bradycardia, HF, PVD, Hypotension Cold extremities, Raynaud’s Bronchospasm, dyspnoea Diarrhoea, N&V, constipation, dry mouth Alopecia, psoriasis exacerbation, rash Sexual dysfunction Fatigue Drug interactions: CCBs, antiarrythmics Warfarin Antidiabetics Antihypertensives Methyldopa, levodopa Ergotamine & derivatives Pregnancy & Breastfeeding: Avoid in pregnancy Growth restriction, hypoglycaemia, bradycardia Avoid in breastfeeding unless essential

Question 32

Topiramate What is it used to treat? Dose? Contraindications? Cautions? SE? Drug interactions? BF?

Answer 32

Migraine and Epilepsy (2nd gen AED) * Initiate at low dose (25mg) and titrate slowly (25-50mg increments) every week * Highly effective contraception needed prior to starting * Can impair some hormonal contraceptives * Women should seek advice if planning a pregnancy * Use in Scotland restricted – try other prophylactic agents first and only use if others have failed Contraindications: **Pregnancy** Children Acute porphyria Cautions: **Women of childbearing age** Breastfeeding Risk of metabolic acidosis Risk of nephrolithiasis Hepatic & renal impairment Side effects: Cognitive impairment, confusion, dizziness, drowsiness Anxiety, depression, suicidal ideation, sleep disturbances Cough, dyspnoea GI disorders Nephrolithiasis Skin disorders Eye disorders Hyperammonaemia +/- encephalopathy Joint disorders, muscle weakness Anaemia Malaise Drug interactions: Oral contraceptives Carbamazepine Phenytoin Valproate Warfarin Breastfeeding: Avoid Suspend breastfeeding or stop/suspend topiramate treatment if breastfeeding benefit outweighs topiramate benefit

Question 33

Amitriptyline Used for? Dose?

Answer 33

Depression, **migraine prophylaxis**, neuropathic pain, abdo pain Dose: **25-75mg at night** SIGN - consider as prophylactic treatment in episodic or chronic migraine NICE –consider for prophylaxis based on patient preference, comorbidities and risk of adverse effects

Question 34

Pizotifen: Who is it indicated for? Dose? Cautions? SE?

Answer 34

Licensed for prophylaxis in young people aged 12-17 On recommendation of specialist Starting dose 500mcg od, inc. up to 1.5mg daily in divided dose Contraindications Acute porphyria Cautions Hx epilepsy Angle-closure glaucoma Urinary retention Avoid abrupt withdrawal Side effects Increased appetite Dizziness, drowsiness, sleep disorders Dry mouth Fatigue, nausea, increased weight, constipation Anxiety, depression

Question 35

What are cluster headaches?

Answer 35

* Classed as a primary headache by ICHD * Part of a group of headaches called Trigeminal Autonomic Cephalalgias * Most common Trigeminal Autonomic Cephalalgia * Frequently recurring, localised, short lasting but severe * Episodic - attacks in period between 7 days to on year with at least 3 month pain free period between attacks * Chronic – attacks for 1 year or longer without a pain free period or a period that lasts less than 3 months * Chronic can become episodic over time or vice versa

Question 36

Cluster Headache

Answer 36

Pathophysiology is complex and not fully understood Synchronised abnormal activity in hypothalamus, trigeminovascular system and ANS Familial link Environmental factors can trigger attacks – alcohol, smoking, histamine, nitrate containing foods, volatile substances Rare disorder, hard to assess true prevalence Peak age of onset aged 20-40yrs More prevalent in men than women - 3:1 ratio Impact on work, home and school life Link with anxiety and depression – fear of pain, relationship issues Can co-exist with other headaches e.g. Migraine

Question 37

Cluster Headache - Symptoms?

Answer 37

* ICHD – at least 5 attacks of severe/very severe unilateral orbital, supraorbital and/or temporal pain lasting 15 mins to 3 hrs At least 1 of: * Conjunctival injection and/or lacrimation * Nasal congestion and/or rhinorrhoea * Eyelid swelling * Forehead and facial sweating * Forehead and facial flushing * Sensation of fullness in the ear * Miosis and/or ptosis (small/constricted pupils, drooping of eyelid) * Restlessness or agitation * Attacks between one every other day and 8 a day and variance in location of attack within the same bout of between bouts, aching headache between attacks

Question 38

Cluster Headache – Differential Diagnosis

Answer 38

Tension Headache Cluster Headache Paroxysmal Hemicrania Cough/cold Headache Trauma/injury to head/neck Intracerebral Haemorrhage Central Venous Thrombosis Giant Cell Arteritis TIA/Stroke Idiopathic Intracranial Hypertension Neoplasm Substance Withdrawal Medication Overuse CO Exposure Intracranial Infection Hypoxia Hypertension Pre-eclampsia/Eclampsia Closed Angle Glaucoma Dental Problem Otitis Media Sinusitis Somatisation Disorder

Question 39

Cluster Headache – Management: How to suspect? How to confirm?

Answer 39

Suspected: * Suspect based on symptoms/features * Refer to specialist if present with red flags or secondary headache suspected * 1st bout – Neurology referral for neuroimaging and confirmation of diagnosis Confirmed: * Advice & Support, information, signposting OUCH UK, Lifting The Burden, Migraine Trust, NHS info, patient.info, BASH * Assess for triggers

Question 40

Cluster Headache – What is the pharmacological management used?

Answer 40

Pharmacological Management: * Triptan therapy for acute attack – over 18s * Subcut/Nasal Sumatriptan * Nasal Zolmitriptan * Oxygen therapy – specialist referral * Prophylactic treatment – Verapamil – Specialist referral if considered Headache diary, especially if co-existing with migraine Regular review to assess response to Treatment

Question 41

Verapamil Drug class? What is it used to treat? Dose? Contraindications? Cautions? Side effects? Interactions?

Answer 41

* Calcium channel blocker * Use in cluster headache prophylaxis is unlicensed * Dose – 240 – 360mg daily in 3-4 divided doses * Contraindications – Acute porphyria, AF, bradycardia, HF with reduced ejection fraction, Hx impaired LV function, hypotension * Cautions – Elderly, acute phase MI, 1st degree heart block, neuromuscular disorders * Side Effects – Abdo pain, dizziness, drowsiness, flushing, headache, nausea, vomiting, palpitations, tachycardia, peripheral oedema, skin reactions * Overdose – CCB poisoning signs include nausea, vomiting, dizziness, agitation, confusion, metabolic acidosis, hyperglycaemia, severe hypotension, peripheral vasodilatation * Interactions – Amiodarone, B-blockers, Statins, Tacrolimus, Phenytoin, Phenobarbital, Lithium