headach

1. Prepared by :
Medical Department of College of Medicine in 21 September University

2.  The international Headache Society has
produced the following diagnostic criteria
for migraine without aura :

3.  At least 5 attacks fulfilling criteria B – D

4.  Headache attacks lasting 4 – 72 hours
( untraeted or unsuccessfully treated )

5.  Headache has at least two of the following
characteristics :
* Unilateral location .
* Pulsating quality ( varying with heartbeat )
* Moderate or severe pain intensity .
* Aggravation by or causing avoidance of
routine physical activity e.g walking or
climbing stairs .

6.  During headache at least one of the
following :
* Nausea and / or vomiting .
* Photophobia and phonophobia .

7.  Not attributed to another disorder ( history
& examination do not suggest a secondary
headache disorder ) .

8.  Attacks may be shorter lasting .
 Headache is more commonly bilateral .
 Gastrointestinal disturbance is more
prominent .

9.  A typical aura may occur hours prior to the
headache .
 Include a transient hemianopic disturbance
, spreading scintilling scotoma & sensory
symptoms may also occur .

10.  Is one which results in hemi sensory or
hemi motor finding associated with a typical
migraine presentation .
 It is like TIA but the pt. is Young age & has
past medical history for migraines .

11.  Acute treatment : used 5 HT 1 Agonist .
 Prophylaxis : used 5 HT 2 antagonist & BB .

12.  Acute : ( Triptan + NSAID ) or ( Triptan +
Paracetamol ) .
 Young People aged 12-17 Years consider a
nasal triptan in perference to an oral
triptan.

13.  If the above measures are not effective or
not tolerated offer a non-oral preparation
of metoclopramide or prochlorperazine &
consider adding a non-oral NSAID or
Triptan .

14.  Prophylaxis : Topiramate or Propranolol .

15.  Prophylaxis should be given if pts. are
experiencing > or = 2 attacks per month .
 Nice advice either Topiramate or
propranolol according to person’s
preference , comorbidities & risk of adverse
events .

16.  Propranolol should be used in preference to
topiramate in women of child bearing age
as it may be teratogenic & it can reduce the
effectiveness of hormonal contraceptives .

17.  If these measures fail NICE recommend a
course of up to 10 sessions of acupuncture
over 5-8 weeks or gabapentin .

18.  NICE recommend : Advise people with
migraine that riboflavin ( 400 mg once a
day ) may be effective in reducing migraine
frequency & intensity for some people .

19.  For women with predictable menstrual
migraine treatment NICE recommend either
frovatriptan or zolmitriptan as a type of
mini-prophylaxis .

20.  Paracetamol 1g is first-line .
 Aspirin 300 mg or Ibuprofen 400 mg can be
used second-line in the first & second
trimester .

21.  Frequency & severity of migraines increase
around the time of menstruation .
 SIGN recommends that women are treated
with mefanamic acid or a combination of
aspirin , paracetamol & caffeine .

22.  Triptans are also recommended in the acute
situation .
 NICE recommend either frovatriptan or
zolmitriptan as a type of mini-prophylaxis .

23.  If pts. Have migraine with aura then the
COC is absolutely CI due to an increased
risk of stroke .
 Ergot derived compounds & Triptans are CI
for treatment of hemiplegic migraine
because of the risk of precipitating a stroke.

24.  Safe to prescribe Hormone replacement
therapy for pts. With a history of migraine
but it may make migraines worse .

25.  Cluster headache are more common in men
& smokers .

26.  Pain typical occurs once or twice a day .
 Episode lasting 15 minutes – 2 hours .
 Clusters typically last 4 – 12 weeks .

27.  Intense pain around one eye ( recurrent
attacks always affect same side ) .
 Accompained by eye redness , lacrimation &
lid swelling .
 Miosis & Ptosis in a minority .

28.  Nasal stuffiness , Rhinorrhoea .
 Pt. is restless during an attack .
 Examination between the attacks should be
normal .

29.  Episodic eye pain , lacrimation , nasal
stuffiness occurring daily >>> Cluster
Headache .

30.  Acute : 100 % oxygen , sc sumatriptan ,
nasal lidocaine .
 Prophylaxis : verapamil , prednisolone .

31.  Consider specialist referral .
 Sumatriptan associated with chest pain
possibly due to vasospasm & also ass. With
MI so contraindicated in pts. With known
IHD .

32.  It is one of the most common causes of
chronic daily headache .

33.  Present for > 15 days per month .
 Developed or worsened while taking regular
symptomatic medication .

34.  Pts. Using opioids & Triptans are at most
risk .
 May be Psychiatric co-morbidity .

35.  Simple analgesia + Triptans :stop abruptly .
 Opioid analgesia : withdraw gradually .

36.  Trigeminal Neuralgia is a pain syndrome
characterised by severe unilateral pain .

37.  The international Headache society defines
trigeminal neuralgia as :

38.  A unilateral disorder characterised by brief
electric shock-like pains , abrupt in onset &
termination , limited to one or more
divisions of the trigeminal nerve .

39.  The pain is commonly evoked by light touch
including washing , shaving , smoking ,
talking & brushing the teeth ( trigger factors
) & frequently occurs spontaneously .

40.  Small areas in the nasolabial fold or chin
may be particularly susceptible to the
precipitation of pain ( trigger areas ) .
 The pain usually remit for variable periods .

41.  Majority of cases are idiopathic .
 Compression of the trigeminal roots by
tumours or vascular problems may occur .

42.  Carbamazepine is first line .
 Failure to respond to treatment or atypical
features ( e.g < 50 Years old ) should
prompt referral to neurology .

43.  Sudden enlargement of pituitary tumour
secondary to haemorrhage or infarction .

44.  Sudden onset headache .
 Vomiting .
 Neck stiffness .

45.  Visual field defects .
 Extra ocular nerve palsies with third nerve
palsy the commonest finding .
 Features of pituitary insufficiency e.g
Hypotension secondary to hypoadrenalism .

46.  MRI Pituitary to confirm the diagnosis .

47.  Hydrocortisone iv should be given to
prevent addisonian crisis .

48.  Avoid aspirin in children < 16 Years as risk of
Reye’s Syndrome .
 Codeine would also be a poor choice as it has
limited benefit in migraine .

49.  Pts. With migraine experience delayed gastric
emptying during acute attacks so decrease effect of
analgesics , for this reason analgesics are often
combined prokinetic agents as metoclopramide .