Headaches & Acute Treatment

Headache is one of the commonest neurological presentations to primary care and neurology clinics.

CLASSIFICATION

The International Headache Society (IHS) classification for headache (ICHD- 2) considers headache disorders to be either primary or secondary. Headaches can be broadly categorized into three groups:

_ Primary headache syndromes

• Migraine with and without aura
• Tension-Type Headache (TTH)
• Cluster headache and other TA Cs, e.g. paroxysmal hemicrania (PH), hemicrania continua (HC), and short- lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
• Other primary headaches, e.g. primary cough, exertional, stabbing and thunderclap headaches, and headache associated with sexual activity.
  
  
  
  
  
  

_ Secondary headache syndromes

• Headaches secondary to head and neck pathology
• Substance use or its withdrawal
• Psychiatric disorder

_ Cranial neuralgias and facial pain, e.g. trigeminal neuralgia

MIGRAINE

Migraine is a common headache disorder. In adults, it is typically unilateral but can be bilateral. It is moderate to severe in intensity, has an insidious onset over minutes to hours, and is described as pulsating or throbbing.

_ Acute treatment of episodic migraine

• First line: aspirin, oral triptan, NSAID, or paracetamol.
• Second line: Non-oral triptan or combination therapy.
• If treatment failure with the above, ergot alkaloids may be used.
• Drugs to avoid: opioids.
• Adjuncts: prokinetic agents, e.g. metoclopramide or domperidone, should be given if there is nausea/ vomiting or suspicion of significant absorption delay due to gastric stasis.

_ Mini- prophylaxis for menstruation- associated migraine

• First line: Short course frovatriptan or NSAID.
• Second line: naratriptan or zolmitriptan

_ Preventative treatment for episodic migraine

• First line: metoprolol, propranolol, topiramate, or sodium valproate.
• Propranolol may be preferred in women of childbearing age, due to the risk of teratogenicity with topiramate and valproate.
• Second line: acupuncture, amitriptyline, flunarizine, or pizotifen.
• Third line: if treatment failure with the above, suggest candesartan, duloxetine, gabapentin, magnesium, methysergide, or venlafaxine.
• Migraine prophylaxis is deemed successful when headache attacks fall by at least 50% in 3 months.

TENSION-TYPE HEADACHE

TTH is the commonest headache type, with a lifetime prevalence of 42% in men and 49% in women. TTH is typically bilateral and is described as a ‘tightening’ or ‘pressure’. It can be associated with muscle tenderness around the head and neck and with nocturnal bruxism.

_ Acute treatment of TTH

• First line: NSAIDs and/ or paracetamol.
• Second line: a combination of NSAIDs or paracetamol with caffeine.
• Drugs to avoid: opioids and triptans.
• Also consider: electromyography (EMG) biofeedback, cognitive
  behavioural therapy (CBT), and relaxation therapy.

_ Treatment of Chronic TTH

• First line: acupuncture or amitriptyline.
• Second line: mirtazapine or venlafaxine

TRIGEMINAL AUTONOMIC CEPHALALGIAS

TA Cs are a group of primary headache disorders that comprise unilateral trigeminal pain with autonomic features such as lacrimation and rhinorrhea.

CLUSTER HEADACHE

Cluster headache is characterized by severe unilateral attacks of orbital/supraorbital/ temporal pain, associated with restlessness and cranial autonomic features (ptosis, miosis, conjunctival injection, lacrimation, nasal congestion, rhinorrhea). The attacks are short- lived (lasting from 15min to 3h), and patients may experience up to eight attacks a day.

_ Acute treatment

• First line: high- flow oxygen (100% oxygen at 10– 15L/ min for 10– 20min with a non- rebreathe mask) and/ or nasal or SC triptan.
• Second line: intranasal lidocaine, SC octreotide, or oral zolmitriptan.
• Drugs to avoid: ergots, hyperbaric oxygen, and opioids

SECONDARY HEADACHE

IDIOPATHIC INTRACRANIAL HYPERTENSION

IIH typically occurs in women who are overweight and of childbearing age. It is also associated with excessive vitamin A intake, growth hormone therapy, and tetracycline antibiotics, and has been linked with certain systemic illnesses, including systemic lupus erythematosus (SLE), hypoparathyroidism, sleep apnoea, and polycystic ovary syndrome (PCOS).

_ MANAGEMENT

• First line: acetazolamide.
• Other drugs to consider: corticosteroids, loop diuretics, topiramate.
• Other management strategies: repeated lumbar puncture (LP), surgery including lumboperitoneal shunting and optic nerve sheath fenestration.

MEDICATION OVERUSE HEADACHE (MOH)

MOH occurs in patients with primary headache disorders who take acute analgesic medication regularly for >3 months. The culprit agents are:

• Ergots, opioids, and triptans for ≥10 days per month;
• Aspirin, NSAIDs, and paracetamol, alone or in combination for ≥15 days per month.

_ MANAGEMENT

_ If drug treatment is also required:

• First- line treatment: topiramate 100– 200mg/ day;
• Second- line treatment: amitriptyline (up to 50mg/ day), corticosteroids (up to 60mg/ day), or NSAIDs