Migraine 1

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Headaches and Migraines

• Course code: PHAR 5717
• Presented by: Dr Maya Saba
• Contact email: [email protected]

Learning Objectives

• Recognize possible underlying conditions related to headaches
• Understand the International Headache Society classification (ICDH-3)
• Understand the pathophysiology of tension-type headaches and migraines
• Identify common symptoms of tension-type headaches and migraines
• Recognize alarm symptoms and referral triggers for tension-type headaches and migraines
• Recommend non-pharmacological, pharmacological and prophylactic interventions for tension-type headaches and migraines
• Explain the underlying cause of medication overuse headaches

Headache

• Universal human experience
• Most common pain experienced by humans
• Most common complaint in medicine and neurology
• Evaluation ranging from straightforward to challenging
• More than 200 different types of headaches

Headache Classification

• International Headache Society Classification is universally accepted
• The International Classification of Headache Disorders-3rd edition (ICDH-3)

Secondary Headache

• Symptoms of an underlying medical condition or drug/medication-induced
• Includes brain tumor, concussion, cervical spine disorders, cerebrospinal fluid disorders, stroke, blood clots, hypertension, glaucoma, meningitis, encephalitis, infections, metabolic disorders, dehydration, drugs (alcohol, cocaine, marijuana, CO2), medications (CCB, nitrates, sildenafil, hormones)

Primary Headaches

• Most common presentation in community pharmacy settings

• 80-90% of community pharmacy headache presentations are tension-type headaches

• 10% are migraines

• Location is a key indicator of headache type

• Tension Headache

  • Typically around the back of the head, temples and forehead with a feeling of a tight hat squeezing the head
  • Sensation of tightness or band-like pressure across forehead
  • Tenderness in scalp, neck, and shoulders
  • Without nausea or vomiting

• Migraine

  • Typically occurs on one side of the head
  • Throbbing or pulsating pain
  • Nausea
  • Vomiting
  • Sensitivity to light and sound

• Cluster Headache

  • Typically behind or around one eye
  • Severe pain
  • Red eye on the affected side
  • Eye tearing
  • Nasal stuffiness
  • Agitation
  • Unable to lie down
  • Onset at 20-40 years of age
  • Rare

Differential Diagnosis Questions

• Age
• Onset of headache
• Frequency, timing and duration of headache
• Location of pain
• Severity of pain
• Triggers
• Associated symptoms
• Recent injury
• History of medication use (Medication Overuse Headache?)

Red Flags for Referral

• Sudden and/or severe onset
• First-ever headache with focal neurological signs, confusion or drowsiness
• Patient older than 50 years (or younger)
• Onset after head trauma or injury
• Frequency or severity increases over weeks to months
• New onset in a patient with HIV, cancer, or immunosuppression
• Signs of systemic illness (e.g. fever, rash, neck stiffness)
• Papilledema (swelling of the optic disc)
• Positional headache (e.g., worse when lying down) or cough headache (especially prolonged)
• Headache unresponsive to analgesics

Differential Diagnosis

• Diagnostic flowchart provided
• Questions asked to determine the type of headache

Tension-Type Headache (TTH)

• Most common type of primary headache
• Lasts 30 minutes to 7 days
• Bilateral dull pain that feels like pressure or tightness
• Mild to moderate intensity
• May not be associated with nausea or vomiting
• Occasionally associated with photophobia or phonophobia

Pathophysiology of TTH

• Not fully understood
• Increased sensitivity to pain
• Altered nociception (detection of painful stimuli) of pericranial myofascial tissue
• Lower tolerance to mechanical, thermal, and electrical stimuli
• More tender percranial myofascial tissue
• Increased excitability of the CNS
• Decreased descending inhibition in supraspinal structures in the CNS
• Increased pain sensitivity
• Epigenetic factors like family history and environmental influences play a role

Non-Pharmacological Treatment

• Regular sleep schedules
• Adequate hydration
• Stress management
• Relaxation techniques (meditation, mindfulness)
• Cognitive behavioural therapy (CBT)
• Physical relaxation
• Physiotherapy (neck muscle stretching and endurance program)
• Acupuncture (6 sessions or more)
• Aerobic exercise
• Trigger avoidance

Pharmacological Treatment

• Simple nonopioid analgesics as mainstay of therapy
• Wait 4-6 hours before repeating dose if needed
• Paracetamol (1g orally, max 4g in 24 hours)
• Aspirin (600-900mg, max 2g in 24 hours)
• NSAIDs (Ibuprofen 400mg, max 2.4g in 24 hours; Diclofenac 50mg, max 150mg in 24 hours; Naproxen 500-750mg, max 1250mg in 24 hours)

Prophylaxis Therapy

• Simple analgesics lose their efficacy over time.

• Consider prophylaxis therapy to reduce analgesic overuse

• Amitriptyline 10mg or Nortriptyline10mg daily, increasing dose by 10mg every 7 days up to max of 75mg

• If effective continue, if not effective after 8-12 weeks, refer to a specialist.

• Mirtazapine 15-30mg or Venlafaxine 75mg, maximum 150mg.

• Morning after food for 8 to 12 weeks as well.

• If effective, continue, if not, refer to a specialist.

Migraines

• Recurrent attacks lasting 4-72 hours.
• Typically one-sided, pulsating pain.
• Moderate to severe intensity.
• Pain aggravated by routine physical activity.
• Nausea and/or vomiting.
• Photophobia, phonophobia, and osmophobia.
• With aura (classic migraine): Reversible focal neurological symptoms developing over 5-20 minutes and lasting less than 60 minutes.
• Without aura (common migraine): 75% of migraine cases.
• Auras affect vision, senses, speech, language, motor function, brainstem and retina.

Migraine with Aura

Migraine Triggers

• Environmental factors (hot wind, barometric pressure changes, loud noises, flashing lights)
• Stress, emotions
• Hormonal changes (puberty, menstruation)
• Food (chocolate, cheese, citrus fruits, preservatives, alcohol)
• Drugs (estrogens, caffeine)
• Sleep deprivation
• Dehydration

Migraine Phases

• Prodrome (few hours to days): irritability, depression, yawning, increased need to urinate, cravings for food, sensitivity to light/sound.
• Aura (5-60 minutes): Visual disturbances, temporary loss of sight, numbness and tingling.
• Headache (4-72 hours): Throbbing, drilling, icepick, burning, nausea, vomiting, dizziness, insomnia, nasal congestion, anxiety.
• Postdrome (24-48 hours): Inability to concentrate, fatigue, depressed mood, euphoria, lack of comprehension.

Pathophysiology of Migraines

• Unknown exact pathophysiology.
• Vascular theory: initial intracerebral vasoconstriction (cause of aura). Extracerebral vasodilation causing headache.
• Inflammation hypothesis: activation of trigeminal nerve terminals in meninges and extracranial vessels.
• Genetic factors and environmental triggers playing a role, causing the release of inflammatory and neuropeptide mediators.
• Calcitonin gene-related peptide (CGRP)

Non-Pharmacological Treatment of Migraine (Including Specific Techniques)

• Cold packs on forehead/back of skull
• Hot packs on neck/shoulders
• Rest in a quiet/dark room
• Avoid physical activity
• Fluid intake
• Physical therapies (massage, stretching, acupuncture, heat, posture)
• Neck stretches and self-mobilisation

Pharmacological Treatment (including specific medication dosage)

• Simple nonopioid analgesics (mainstay of therapy).

• Wait 4-6 hrs before repeating a dose

• Paracetamol (1g orally, max 4g in 24 hrs).

• Aspirin (900-1000 mg, max 4g in 24 hrs).

• NSAIDs (Ibuprofen 400mg, max 2.4g in 24 hrs, Diclofenac 50mg, max 150mg in 24 hrs, Naproxen 500/750mg, max 1250mg in 24hrs)

• Metoclopramide (10mg orally, max 30mg).

• Domperidone (10-20mg).

• Ondansetron (4-8mg orally, max 16mg).

• Prochlorperazine (5-10mg orally, max 30mg).

• Triptans (oral, nasal spray, injectable)

  • Avoid if taking ergometrine or if used within 24 hrs of another triptan).
  • Monitor for serotonin toxicity.

Other Migraine Supplements

• Magnesium (400-650mg daily).
• Co-Enzyme Q10 (150-300mg daily)
• Riboflavin (Vitamin B2), (200mg twice daily)

Lifestyle Modifications

• Regular Sleep schedules
• Minimal variation in blood sugar concentrations (avoid simple carbohydrates )
• Adequate hydration (1.5 to 2 liters daily)
• Limited caffeine (1-2 cups daily)
• Regular exercise (30-40 minutes, 3-4 times per week).
• Regular physiotherapy
• Good workspace ergonomics (stretch frequently)
• Avoid triggers (stress, alcohol, perfume)
• Headache diary

Medication Overuse Headache (MOH)

• Rebound headache as the dose wears off.
• Could result in secondary headache disorder.
• Exact pathophysiology is unknown.
• More common in patients with TTH or migraine.
• Patients with >15 days/month for >3 months headache frequency.
• Taking >10 days/month of triptans, opioid analgesics, and ergotamines.
• Taking >15 days/month of nonopioid analgesics
• Typically resolves after overuse is stopped

Prophylaxis Treatment

• Requires a month's trial to consider
• Use lowest effective dose
• 8-12 weeks therapy
• Monitor efficacy and adverse effects
• Caution about pre-existing conditions and medications

Comorbidity Consideration

• Asthma, insomnia, anxiety, postural orthostatic tachycardia syndrome, obesity, diabetes, fibromyalgia.
• History of renal calculi, neck muscular tension, and bruxism.

Further Resources

• International Headache Society (www.ichd-3.org)
• Migraine & Headache Australia(headacheaustralia.org.au/types-of-headaches)
• Migraine Australia (www.migraine.org.au)
• Rutter P. Community Pharmacy. 5th Edition

Further information

• The University of Sydney