Primary headache

• The most common primary headaches are tension headaches, migraines and cluster headaches - Trigeminal neuralgia is a type of cluster headache
• Migraine is a common headache disorder that mostly affects young women. Migraine can be categorised into four main types:

  • Migraine with aura
  • Migraine without aura
  • Silent migraine - migraine with aura but without a headache
  • Hemiplegic migraine
• There are 5 stages of a migraine:

  • Prodromal stage (can begin several days before the headache)
  • Aura (lasting up to 60 minutes)
  • Headache stage (lasts 4 to 72 hours)
  • Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
  • Postdromal or recovery phase
• An aura before a migraine can affect vision, sensation or language. Visual symptoms are the most common:

  • Sparks in the vision
  • Blurred vision
  • Lines across the vision
  • Loss of visual fields
• Typical features of a migraine:

  • Usually unilateral
  • Moderate-severe intensity
  • Pounding or throbbing in nature
  • Photophobia
  • Phonophobia
  • Osmophobia
  • Aura
  • Nausea and vomiting
• Triggers for migraine headache:

  • Stress
  • Bright lights
  • Strong smells
  • Certain foods - chocolate, cheese and caffeine
  • Dehydration
  • Menstruation
  • Disrupted sleep
• Acute migraine treatment:

  1. NSAID or paracetamol
  2. Oral sumatriptan alone or in combination with NSAID or paracetamol
  3. Consider an anti-emetic on top of other medications
• Opioids should be avoided in the treatment of a migraine
• Prophylaxis treatment for migraine:

  • Propranolol (first line)80-160mg
  • Topiramate 50-100mg - contraindicated in pregnancy
  • Amitriptyline 25-75mg
• Do not offer gabapentin for migraine prophylaxis
• Acupuncture can be given for migraine prophylaxis if medical treatment is ineffective
• Tension headaches are very common. They typically cause a mild ache or pressure in a band-like pattern around the head. They develop and resolve gradually and do not produce visual changes
• Management of a tension headache is simple analgesia such as ibuprofen or paracetamol, and reassurance. Do not offer opioids for the treatment of a tension headache. Amitriptyline can be given for chronic tension headaches.
• Cluster headaches are severe and unbearable unilateral headaches, usually centred around the eye. They come in cluster of attacks and then can disappear for extended periods.
• A typical patient suffering with cluster headaches is a 30-50 year old male smoker. They may have triggers such as alcohol, strong smells or exercise.
• Cluster headaches cause severe pain. They are sometimes called “suicide headaches” due to their severity.

  Associated symptoms are typically unilateral on the same side as the pain:

  • Red, swollen and watering eye
  • Pupil constriction (miosis)
  • Eyelid drooping (ptosis)
  • Nasal discharge
  • Facial sweating
• Treatment of an acute cluster headache attack:

  • Sub cut or nasal triptan (do not offer oral)
  • High flow 100% oxygen - may be kept at home
  • Do not offer paracetamol, NSAIDs, opioids or oral triptans
• First line prophylaxis for cluster headaches is verapamil
• Trigeminal neuralgia causes intense facial pain in the distribution of the trigeminal nerve, which has three branches. It is more common in patients with multiple sclerosis.
• Symptoms of trigeminal neuralgia:

  • Normally unilateral
  • Pain comes on suddenly and can last seconds to hours
  • Electricity-like, shooting, stabbing or burning pain
• Trigeminal neuralgia can be triggered by touch, talking, eating, shaving or cold weather
• Most cases are causes by vascular compression of the trigeminal nerve root. It is important to rule out any red flags such as tumours, infections, or trauma.
• Classical trigeminal neuralgia is treated with carbamazepine - an anticonvulsant
• Medication overuse headache= headache occurring more than 15 days per month in a patient with a pre-existing headache disorder
• Medication overuse headache develops when a person uses high levels of acute medicines for at least three months:

  • Simple analgesics on 15 or more days per month
  • Codeine-based medicines on 10 or more days per month
• Triptans selectively bind to the serotonin receptors 5-HT1B and 5-HT1D which leads to vasoconstriction of the cranial arteries which painfully dilate during a migraine attack
• Diclofenac is an NSAID that can be given to treat an acute migraine attack
• Migraine prophylaxis:

  • 1st line is propranolol
  • Amitriptyline - tricyclic antidepressant
  • Topiramate - antiepileptic
  • Candesartan - ARB
  • Sodium valproate - must not be used in pregnancy
• Metoclopramide and prochlorperazine are anti-emetics that can be used to treat nausea and vomiting associated with migraines
• amitriptyline can be used for frequent or chronic tension type headaches