Headachediagnosis and treatment :

now and the future

Paul Rolan MBBS MD FRACP FFPM DCPSA

Professor of Clinical Pharmacology

Senior Consultant, Pain Management Unit, RAH

Headache

• in 99.9% of people with headache there is no sign of tissue damage

• injuring the brain itself does not cause pain – it causes altered brain function

• however the membrane and blood vessels of the brain are very pain sensitive

Headache: causes

• Primary (99%+)• Tension – type 69• Migraine 16• Stabbing 2• Exertional 1• Cluster 0.1

• Due to something else (<1%)

• Systemic infection 63• Head injury 4• Vascular / bleeding 1

• Brain tumour0.1

Headache diagnosis

• almost entirely on the patients story• tests, scans etc rarely helpful.

Headache: history

• How old were you when the headaches started?• How often do they come?• Do they come in relationship to anything else?• At what time do they come on?• How do they start?• Where is the pain? • How long does it last?• How bad is it?• Are there other symptoms?• Does anything bring it on?• What helps?• How long does it last?

Pattern recognition

pick the odd one out

Tension-type Headache• Frequency chronic

often daily

• Pain mild-moderatepressure, tightness

• Duration 30 mins - 7 days

• Location both sideswhole head and neck

• Symptoms no light / sound sensitivityno aura

Typical patient : any

Typical patient : any

Tension-type headache

• now thought to be due to increased brain sensitivity to normal sensory inputs

• few effective treatments : we are trialling a non-drug treatment

Migraine (“half-head”)• Frequency 1-2/year- 2-3/week

• Pain moderate - severepulsating, throbbing

• Duration 4 hrs - 3 days

• Location usually one sided (but side can swap between attacks)

• Symptoms auranausea, vomitingsensitive to light, sound, smells

Typical migraine patient

• onset often as child / teenager / young adult• but can start at any age

• 2-3 x more common in women than men• typical patient : young woman (15% of all young women)

What happens during a migraine?

Migraine cause

• cause unknown but strongly inherited• a lower threshold to spontaneously produce symptoms as if

the head and brain had been injured• many effective treatments

Triggers

• foods : spices, wine , chocolate, citrus• food additives : monosodium glutamate• sleep : both too much and too little• stress : mainly offset• female hormones : fluctuating or falling oestrogen

Migrainous Aura

Migrainous Aura

Migrainous Aura

Medication overuse headache

• headache made WORSE by pain killers• only occurs in people who already had headache• mainly due to codeine-containing medicines or stronger

morphine-like drugs• need to stop responsible medicines : easier said than done• we are trialling a new treatment for this

Cluster Headache• Frequency clusters – every time each year or season;

then free

• Pain excruciatingpenetrating, boringcontinuous, non-throbbing

• Duration 15mins-3 hrs; same clock time each day (2am); several episodes / day

• Location ALWAYS the same side

• Symptoms watering eyesnasal stuffiness, runny nosered eye, swollen eyelidssweating

Typical patient : middle aged male smoker

Cluster Headache

Trigeminal Neuralgia• VERY short (<1 sec) severe

pain

• Knife-like

• Local triggering : eating etc

Typical patient : middle aged / elderly woman

Other headaches

• Paroxysmal hemicrania• “SUNCT”

– short lasting neuralgiform;conjunctival injection, tearing

• Stabbing headaches• After head injury / head surgery• Sexual headaches• Altitude sickness

TreatmentExplanation, set realistic objectives

Lifestyle change

Treatment of the attack

Treatment to reduce attack frequency

Treatment of the attack

1 General pain relievers

2 Migraine-specific treatments

- triptans and ergots

3 Cluster specific treatment

- oxygen

- triptans

General pain relievers : migraine, tension

aspirin paracetamol ibuprofen codeine tramadol

Fast? ✔✔ ✔ ✔

Safe? ✔✔

OK for long term?

✖ ✔✔ ✖ ✖✖✖

Not suitable : dextropropoxyphene “Doloxene; Di-Gesic” morphine, pethidine

Additives : metoclopramide (nausea) caffeine

Triptans : Imigran, Zomig, Naramig, Maxalt, Relpax

FOR• can be very

effective : migraine, cluster (NOT tension)

• tablets, wafers, nasal spray, injection

• AGAINST• feel strange, chest

pain• expensive, small

supply• overuse makes

headaches more frequent

• constrict blood vessels

Ergots : migraine, cluster

FOR• can be very

effective when others fail

• nasal spray, suppository injection

• AGAINST• hard to get• overuse causes

poor circulation and more headache

• not for tension

Preventative drugs

• “mixed bag” of drugs used for other conditions found to be effective in headache usually by chance

• usually for high blood pressure, depression, epilepsy• all work in somebody ; none works in everybody• generally reduce frequency but do not change attacks• key to success : trial and error : persist• need to start at low dose and increase until effective or not

tolerated• about 50 % of patients will get 50% or more reduction in

attacks

Main migraine preventers

Effectiveness

Tolerability / safety Good Fair Poor

Good propranolol verapamil

Botox

Fair amitriptyline

topiramate

valproate

pizotifen

ibuprofen

Poor methysergide

Tension preventers

Effectiveness

Tolerability / safety Good Fair Poor

Good

Fair amitriptyline ibuprofen

Poor

Cluster preventers - balance of effectiveness and safety /

tolerabilityEffectiveness

Tolerability / safety Good Fair Poor

Good verapamil

Fair topiramate

Poor methysergide

steroids

lithium

Non drug

Herbal•feverfew – no•butterbur – possibly

Manual therapies•physiotherapy – caution•acupuncture – no

Electrical occipital nerve stimulation : possibly

Closure of hole in heart - no

In the pipeline

In the pipeline

• “vaccination” for migraine• new classes of drugs

Our research

• we are trialling a non-drug electrical therapy for tension-type headache

• we are trialling a completely new drug approach to medication overuse headache

• we may be trialling new agents for migraine in the near future

http://www.adelaide.edu.au/painresearch/participate/