2. 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
6. 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?
8. Tension-type Headache
• Frequency chronic
often daily
• Pain mild-moderate
pressure, tightness
• Duration 30 mins - 7 days
• Location both sides
whole head and neck
• Symptoms no light / sound sensitivity
no aura
Typical patient : any
10. 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
11. Migraine (“half-head”)
• Frequency 1-2/year- 2-3/week
• Pain moderate - severe
pulsating, throbbing
• Duration 4 hrs - 3 days
• Location usually one sided (but side can swap
between attacks)
• Symptoms aura
nausea, vomiting
sensitive to light, sound, smells
12. 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)
14. 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
15. 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
19. 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
20. Cluster Headache
• Frequency clusters – every time each year or season;
then free
• Pain excruciating
penetrating, boring
continuous, non-throbbing
• Duration 15mins-3 hrs; same clock time each day
(2am); several episodes / day
• Location ALWAYS the same side
• Symptoms watering eyes
nasal stuffiness, runny nose
red eye, swollen eyelids
sweating
Typical patient : middle aged male smoker
22. Trigeminal Neuralgia
• VERY short (<1 sec) severe
pain
• Knife-like
• Local triggering : eating etc
Typical patient : middle aged / elderly woman
23. Other headaches
• Paroxysmal hemicrania
• “SUNCT”
– short lasting neuralgiform;conjunctival injection, tearing
• Stabbing headaches
• After head injury / head surgery
• Sexual headaches
• Altitude sickness
25. Treatment of the attack
1 General pain relievers
2 Migraine-specific treatments
- triptans and ergots
3 Cluster specific treatment
- oxygen
- triptans
26. 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
27. 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
28. 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
29. 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
32. Cluster preventers - balance of
effectiveness and safety /
tolerability
Effectiveness
Tolerability / safety Good Fair Poor
Good verapamil
Fair topiramate
Poor methysergide
steroids
lithium
33. Non drug
Herbal
•feverfew – no
•butterbur – possibly
Manual therapies
•physiotherapy – caution
•acupuncture – no
Electrical occipital nerve stimulation : possibly
Closure of hole in heart - no
36. 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
