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56 Cards in this Set
- Front
- Back
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primary headache
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migraine, cluster, tension (90%)
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secondary headache
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tumor, meningitis, vascular condition (10%)
symptom of underlying condition often caused by fasting, sinusitis, head trauma. |
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how to determine if primary or secondary
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secondary will have associated symptoms (fever, visual disturbances, weight loss)
a headache (other than recurrent) sudden onset over 50yo have other systemic disease (AIDs, cancer) change in frequency, duration, severity neurological symptoms REFER ALL OF THESE |
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why are primary headaches syndromes
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constellation of symptoms and signs
pain and presence or absence of associated features |
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goals of headache therapy
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1. identify cause (rule out 2ndary)
2. determine when to refer 3. relief pain or symptoms (N/V) 4. prevent recurrence (identify triggers) 5. prevent complications of medication overuse |
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tension headaches (3 types)
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episodic
chronic chronic 'transformed' migrane |
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episodic tension headache
diagnosis |
most common
variable features <15 days/month or 180 days/ year based on absence of migrane features |
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chronic tension headache
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occurs with increased frequency
more than 15 days a month for more than 4 hours a day for more than 6 months |
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tension headache symptoms
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symptoms - dull, achy, bilateral, non-pulsating
mild to moderate pain pressing or tightening not aggravated by physical activity no vomiting, or nausea, photophobia or phonophobia no aura or prodome |
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treatment for tension headaches
non pharmacological |
effective and safer
exclude triggers, decrease caffeine, increase exercise, heat, massage |
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treatment acute headaches
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respond to simple analgesia
e.g. paracetamol, aspirin, ibuprofen, naproxen |
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treatment chronic headache
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analgesics often ineffective
non pharmacological intervensions are best |
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mixed tension/migrane headaches or frequent/persistant
what action should be taken |
amitriptyline, sodium valproate
refer |
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cluster headaches
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1 or 2 per year (lasts 1-3months, may be seasonal)
will occur at same time each year for each patient 1-3 per day usually at same time each day. circadian rhythm (biological clock set by recurring daylight and darkness) uncommon more prevalent in males genetic predisposition severe, unilateral, pain around eyes and face, lasts 15 min - 3 hrs |
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autonomic features of cluster headaches
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tears, conjestion, runny nose
swelling, miosis (constriction of pupil), ptosis (drooping of eye), eyelid oedema. |
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chronic 'transformed' migrane
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daily or almost daily head pain (more than a month)
must have had at least one migrane hx of increased frequency but decreased severity of migrane features. |
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migrane
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female more common
5 attacks lasting 4-72 hours unilateral pulsating moderate-severe intensity aggravated by routine exercise nausea, vomiting, photophobia, phonophobia |
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direct and indirect costs
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direct: medical care, medications
indirect: disruption of activities/work |
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association with other disorders
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neurological (epilepsy), medical disorders (raynaud's syndrome -> constriction of bvs, asthma) psychiatric (depression, anxiety, panic disorder, manic-depression/bipolar disorder
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chance of getting migrane increased by:
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menstrual cycle
chocolate, strawberries paradoxyl relationship to sleep (will wake up with migrane) yet can be abated by sleep family history cognitive impairment dizziness and vertigo |
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drug-induced headaches
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e.g. nitrates, beta-blockers, ACEI, SSRI, oral contraception pill/HRT, caffeine
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medication rebound headaches
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occur in 80% patients
more common in migrane sufferers more common in females no relationship to dosage used or time to rebound |
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medications with rebound headache
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time to take them which gives rebound headache
simple analgesics - paracetamol, NSAIDS - 5 days per week triptans - sumatriptan - 3 days per week opioids - codeine, tramadol - 2 days per week ergotamine - ergotamine - 2 days per week |
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write out HA clinical features table
tension, migrane and cluster for quality severity location frequency duration aggravated by physical activity associated Sx |
see table last page of headache 1 :)
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migraine two theories
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vascular - (blood vessel constriction = aura followed by blood vessel dilation = headache)
serotonin (decreased serotonin levels linked with migraine) |
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neurovascular process of migrane
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neural event (e.g. drop in 5-ht) --> activation of BV --> pain and further nerve activation
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migraine diagnosis
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medical history (family history of migraines, medical conditions, other meds [may be symptom or side effect])
headache diary to be able to find triggers investigations to exclude secondary causes |
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migraine classification
3 types |
common migraine - without aura (unilateral throbbing possibly with n/v, phonophobia and photophonia)
classic migrane - with aura (unilateral throbbing and later becomes generalised, visual disturbances and mood variations) complicated migraine |
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prodrome
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60% people have
25% people feel elated, irritable, depressed, hungry, thirsty or drowsy. warning state days to weeks before HA changes in mental state (drowsiness) and neurological changes (phonophobia) |
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aura
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neurological symptom
visual and somatosensory (e.g. speech/language problems, motor) persist 20-60 minutes starts and terminates before HA |
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aura symptoms
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visual (scotoma, fortification spectra[zig-zag], scintillations)
motor (hemiparesis) sensory (numbness, dysasthesias), complicated (basilar, ophthalmoplegic) |
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post headache symptoms
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mood changes, muscular weekness, physical tiredness, reduced appetite
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triggers/aggravating factors of migraines
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skipping meals, medication overuse, changes in circadian rhythms [jetlag], weather changes [lightening], fragrances/odors, hormones, stress/overexertion
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treatment strategies for migraines
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individual management required
dep on severity and frequency, disability, associated symptoms, prior response to meds, underlying conditions. |
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acute migraine therapy
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treat rapidly and consistently
restore function involved in selfcare MIGRAINE SPECIFIC AGENTS - first line treatments (triptans and ergots) used if poorly respond to NSAIDs |
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route of admin migraine therapy
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non-oral when severe N/V
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acute migraine treatments - analgesics
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simple analgesics (soluble aspirin, soluble paracetamol)
compound analgesics (with codeine but single ingredient are better) |
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NSAIDs in acute migraine treatments
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NSAIDs (effective, can be associated with rebound if taken more than 5 times a week, can reduce serotonin, NOT indomethacin [can cause headaches])
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ergotamine in acute migraine treatments
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grandfather drug (therefore no clinical trials just long use)
if no response to analgesics 80% short-half life more effective if given earlier (start orally at prodrome/aura or HA onset) MOA: vasoconstrictor of smooth muscle in cranial BV, a-adrenergic agonist, weak b-agonist (dopamine 1&2) |
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caffine in acute migraine treatments
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can be used with ergotamines
adjunct analgesic which may promote absorption but can lead to dependence. |
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SE: ergotamines with/without caffine
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increased blood pressure & peripheral ischaemia (e.g. gangreen), drowsiness, fatigue
LIMIT DOSE |
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ergotamines / caffine
contraindicated |
coronary artery disease, hypertension, peripheral vascular disease, hyperthyroidism, pregnancy and children.
DRUG INTERACTION: triptans, b blockers, dopamine agonists. |
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e.g. of ergotamine
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dihydroergotamine
weaker version of ergotamine promotes n/v |
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triptans dosage form
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oral [14%]; subcutaneous [96%]; nasal spray
bioavail [] |
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reason for using triptan
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if simple analgesic AND ergotamine FAILED :(!!!!
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MOA triptans
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constrict cranial vessels by selective 5-HT1 agonist
does not cross BBB |
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effectiveness of triptans
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sucess within 2-4hrs for 50-70%
HA recurrence is common within 24 hours in 30-40% patients can give repeat dosing but maybe no benefit if no initial response |
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e.g. of triptans
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sumitriptan, zolmitriptan, naratriptan.
z & n penetrate BBB NONE REALLY BETTER THAN OTHERS |
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SE triptans
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rebound headache
bad taste, n, v, fatigue, diziness, vertigo. |
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contraindications triptans
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IHD, angina, previous MI, uncontrolled hypertension, ischaemic stroke, PVD
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DI with triptans
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ergotamines (Additional vasocontriction +++)
ergotamine | WAIT 24HOURS | triptan | WAIT 6 HOURS | ergotamine best not to use at all mao inhibitor (2 weeks) SSRIs; st johns wort |
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goals of preventative treatments
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reduce frequency, duration, severity and improve response to acute treatments, improve function and reduce disability
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three types of preventative Tx
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episodic (trigger e.g. sex, exercise -> treat prior to exposure)
subacute (time-limited e.g. menstruation -> treat before and during) chronic (ongoing susceptibility -> treat on regular regimen) |
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preventative treatments (6)
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anticonvulsants, antidepressants, b blockers, calcium channel antagonists, serotonin antagonists, NSAIDs
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preventative treatment
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start low, go slow
2-6 months before benefit avoid interfering, overuse and contraindicated |
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non-drug therapy for migraines
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if drugs cant be used
behavioural - relaxation, hypnotherapy physical treatments - acupuncture, TENS |
