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HEADACHE SLIIDE SHARE.pptx primary headache
- 1. HEADACHE – DIAGNOSIS AND MANAGEMENT MODERATOR: Dr. Adarsh Tripathi, M.D Dr. Aathira J Prakash Junior Resident
- 2. • Headache is among the most common reasons patients seek medical attention. • Prevalence among adults of current headache disorder (symptomatic at least once within the last year) is about 50%. • The observed 1-year prevalence of any headache was 63.9 %, with a female preponderance of 4:3. • The 1-year prevalence of migraine was 14.12% and DALY showed maximum burden among women in the age range of between 30 and 34 years.
- 3. • International headache society characterizes headache as primary and secondary • Primary headache and its associated features are the disorder in itself • Secondary headache is caused by exogenous disorder
- 4. PRIMARY HEADACHE International Classification of Headache Disorders-3 classify primary headache as: 1. Migraine 2. Tension-type headache 3. Trigeminal autonomic cephalgias (Cluster headache) 4. Other primary headache disorders
- 5. MIGRAINE • The 2016 Global Burden of Disease data revealed that migraine was the second most disabling condition worldwide.
- 6. • Classification as per ICHD-3: • Migraine without aura • Migraine with aura • Chronic Migraine • Complications of Migraine • Probable migraine • Episodic syndromes that may be associated migraine
- 7. • Migraine without aura : Recurrent headache disorder manifesting in attacks lasting 4-72 hours with typical characteristics of migrainous headache. • Migraine with aura : Recurrent attacks, lasting minutes, of unilateral fully- reversible visual, sensory or other central nervous system symptoms that is followed by headache. • Chronic Migraine : Headache occurring on 15 or more days/month for more than 3 months, which, on at least 8 days/month, has the features of migraine headache.
- 8. Complications of migraine: Status Migrainosus Persistent aura without infarction Migrainous infarction Migraine aura-triggered seizure Probable migraine: Probable migraine without aura Probable migraine with aura Episodic syndromes that may be associated with migraine: Recurrent gastrointestinal disturbance Cyclical vomiting syndrome Abdominal migraine Benign paroxysmal vertigo Benign paroxysmal torticollis
- 9. Diagnostic criteria for Migraine without aura(ICHD-3) A. At least five attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs) D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis.
- 10. Diagnostic criteria for Migraine with aura (ICHD-3) A. At least two attacks fulfilling criteria B and C B. One or more of the following fully reversible aura symptoms: 1. visual 2. sensory 3. speech and/or language 4. motor 5. brainstem 6. retinal C. At least three of the following six characteristics: 1. at least one aura symptom spreads gradually over ≥5 minutes 2. two or more aura symptoms occur in succession 3. each individual aura symptom lasts 5- 60 minutes1 4. at least one aura symptom is unilateral2 5. at least one aura symptom is positive3 6. the aura is accompanied, or followed within 60 minutes, by headache
- 11. • Chronic migraine : • Headache occurring on 15 or more days/month for more than 3 months, which, on at least 8 days/month, has the features of migraine headache • The characteristics of the headache may change not only from day to day but even within the same day. • Attacks with and those without aura are both counted, as are both migraine- like and tension-type-like headaches (but not secondary headaches) • The most common cause of symptoms suggestive of chronic migraine is medication overuse,
- 12. Co-morbidities associated with Migraine • Cardiovascular disorders • Psychiatric disorders • Neurologic diseases • Sleep conditions • Inflammatory conditions • Chronic pain conditions
- 13. Management of migraine • Comprehensive management: • Non-pharmacological management • Treatment of Acute attacks • Prevention of migraine
- 14. • NON – PHARMACOLOGICAL MANAGEMENT: • Encourage patients to participate actively in their treatment and to employ self- management principles • Pay attention to lifestyle and specific migraine triggers in order to reduce the frequency of attacks
- 16. • MANAGEMENT OF ACUTE ATTACK 1. Analgesics: • Acetaminophen 1000 mg • Ibuprofen 400 mg, • ASA 1000 mg • Naproxen sodium 500-550 mg • Combination analgesics including caffeine • Antiemetics: domperidone 10 mg or metoclopramide 10 mg for nausea
- 17. 2. Triptans: • Oral : • Sumatriptan 100 mg • Rizatriptan 10 mg • Zolmitriptan 2.5 mg • Naratriptan 2.5 mg • Subcutaneous sumatriptan 6 mg if the patient is vomiting early in the attack. • Nasal spray: zolmitriptan 5 mg or sumatriptan 20 mg if patient is nauseated 3. Naproxen sodium 500-550 mg in combination with a triptan
- 18. • PROPHYLAXIS OF MIGRAINE: When to consider? • Recurrent migraine attacks are causing considerable disability despite optimal acute drug therapy • Frequency of acute medication use is approaching levels that place the patient at risk of medication-overuse headache • Recurrent attacks with prolonged aura are occurring (hemiplegic migraine, basilar-type migraine, etc) • Contraindications to acute migraine medications are making symptomatic treatment of migraine attacks difficult
- 19. • Principles of preventive treatment • Use the least amount of the medication with the fewest side effects • Initiate therapy with medications that have the highest level of efficacy • Increase the dose slowly until clinical benefits are achieved without adverse events • Give each drug an adequate trial of at least 2 to 3 months
- 20. • Use a long acting formulation, it will help improve compliance • Monitor the patient's headache frequency using a headache diary • Select a drug that will treat the coexistent condition and migraine • Direct special attention to women who are pregnant or desire to conceive
- 21. • Beta-blockers : • Propranolol, atenolol, and metoprolol • Contraindicated in patients with asthma, chronic obstructive pulmonary disease, insulin-dependent diabetes mellitus, heart block or failure, or peripheral vascular disease. • Propranolol can be started in a dose of 10 mg twice daily and gradually increased to a maximum of 80-120 mg per day
- 22. • Calcium channel blockers : • Flunarizine is most commonly used for migraine prophylaxis • Dose - 10 mg/day • Flunarizine is to be avoided in patients with depression • Calcium-channel blockers are contraindicated in patients with hypotension, congestive heart failure, or arrhythmia
- 23. • Tricyclic antidepressants: • Amitriptyline is useful in migraine, especially in patients with associated TTH • Dose- 25-50 mg/ day • Contraindications include cardiac, kidney, liver, prostate and thyroid disease, glaucoma, hypotension, seizure disorder, and use of monoamine oxidase inhibitors. • Use with caution in elderly.
- 24. • Anti-epileptics : • Sodium valproate, valproic acid, divalproex sodium, and topiramate have been found to be effective for migraine prophylaxis • Should not be given to women who are pregnant or considering pregnancy or young women with polycystic ovarian disease (PCOD) • Divalproex is started in a small dose of 250-500 mg per day and the dose is gradually increased up to 1500 mg per day with continuous monitoring for side-effects
- 25. • Topiramate should be started in a small dose of 25 mg per day in adults and the dose should be gradually increased in 25 mg weekly increments to a maximum of 100 mg twice daily • Topiramate has the advantage of weight loss and can be used in preference to divalproex when treating obese patients • Topiramate should not be used in the presence of glaucoma, renal stones
- 26. TENSION TYPE HEADACHE • Very common, with a lifetime prevalence in the general population ranging between 30% and 78% • More common in women than men
- 27. ICHD-3 classification of TTH: 1. Infrequent episodic tension-type headache a) associated with pericranial tenderness b) not associated with pericranial tenderness 2. Frequent episodic tension-type headache a) associated with pericranial tenderness b) not associated with pericranial tenderness 3. Chronic tension-type headache a) associated with pericranial tenderness b) not associated with pericranial tenderness 4. Probable tension-type headache a) Infrequent episodic b) Frequent episodic c) Chronic
- 28. Diagnostic criteria for infrequent episodic TTH 1.At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year) and fulfilling criteria B-D 2.Lasting from 30 minutes to 7 days 3.At least two of the following four characteristics: a) bilateral location b) pressing or tightening (non-pulsating) quality c) mild or moderate intensity d) not aggravated by routine physical activity such as walking or climbing stairs 4. Both of the following: a) no nausea or vomiting b) no more than one of photophobia or phonophobia 5.Not better accounted for by another ICHD-3 diagnosis.
- 29. Diagnostic criteria for frequent episodic TTH 1.At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months (≥12 and <180 days/year) and fulfilling criteria B-D 2.Lasting from 30 minutes to 7 days 3.At least two of the following four characteristics: a) bilateral location b) pressing or tightening (non-pulsating) quality c) mild or moderate intensity d) not aggravated by routine physical activity such as walking or climbing stairs 4. Both of the following: a) no nausea or vomiting b) no more than one of photophobia or phonophobia 5.Not better accounted for by another ICHD- 3 diagnosis.
- 30. • Chronic tension-type headache : • Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year) • Episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting hours to days, or unremitting. • The pain does not worsen with routine physical activity, but may be associated with mild nausea, photophobia or phonophobia. • In many uncertain cases there is overuse of medication.
- 31. Co-morbidities of TTH • Psychiatric diorders : • GAD • MDD • Suicidal ideation
- 32. Management of Tension type headache • Acute abortive treatment • Simple analgesics and NSAIDSs are the mainstays in the acute therapy • Preventive treatment: • Tricyclic antidepressants: Amtriptlyline has been found to be most effective, should be started on low dose (10 mg to 25 mg per day) and titrated by 10-25 mg weekly • Mirtazepine upto 30 mg/day can be given as second line
- 33. • Non- Pharmacological Management of TTH: • Relaxation training : The goal is to help the patient to recognize and control tension as it arises in the course of daily activities. • EMG biofeedback : The aim is to help the patient to recognize and control muscle tension by providing continuous feedback about muscle activity.
- 34. • Cognitive-behavioural therapy : The aim of is to teach the patient to identify thoughts and beliefs that generate stress and aggravate headaches • Physical therapy : includes the improvement of posture, relaxation, exercise programs, hot and cold packs, ultrasound and electrical stimulation. • Acupuncture and nerve block
- 35. TRIGEMINAL AUTONOMIC CEPHALALGIAS • The incidence of TACs is low, with Cluster Headache being the most common with a prevalence of approximately 0.1% of the population • Simultaneous activation of the trigeminal system and of the autonomic nervous system is a common feature of all trigeminal autonomic cephalalgias • Produces the clinical picture of short-lasting, strictly unilateral headache attacks with ipsilateral autonomic symptoms.
- 36. ICHD-3 Classification of Trigeminal autonomic cephalgias: 1. Cluster headache a) Episodic b) Chronic 2. Paroxysmal hemicrania a) Episodic b) Chronic 3. Short-lasting unilateral neuralgiform headache attacks a) Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) b) Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) 4. Hemicrania continua 5. Probable trigeminal autonomic cephalalgia
- 37. CLUSTER HEADACHE • Age at onset is usually 20-40 years. • Men are afflicted three times more • Can be episodic or chronic
- 38. Diagnostic criteria for Cluster Headache 1. At least five attacks fulfilling criteria B-D 2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated) 3. Either or both of the following: a) at least one of the following symptoms or signs, ipsilateral to the headache: – conjunctival injection and/or lacrimation – nasal congestion and/or rhinorrhoea – eyelid oedema – forehead and facial sweating – miosis and/or ptosis b)a sense of restlessness or agitation 4. Occurring with a frequency between one every other day and 8 per day 5. Not better accounted for by another ICHD-3 diagnosis.
- 39. • Attacks occur in series lasting for weeks or months (so-called cluster periods or bouts) separated by remission periods usually lasting months or years. About 10-15% of patients have Chronic cluster headache • Chronic cluster headache : Cluster headache attacks occurring for one year or longer without remission, or with remission periods lasting less than 3 months.
- 40. Management of Cluster Headache • Cluster Headache are primary in nature, but may be a rare manifestation of an underlying space-occupying lesion, (especially pituitary tumors) • Hence neuroimaging studies of all cases of CH are recommended. • Treatment includes abortive treatment for acute attacks and preventive treatment
- 41. • ABORTIVE TREATMENT: • SC sumatriptan: Given as ½ cc = 6 mg SC injection OR • Intranasal sumatriptan (20 mg ) or Zolmitriptan (5mg) • Oxygen: Inhalation of 100% oxygen at 6-7 L/min for 15 min is effective in 60% cases. Higher flow rate (12 L/min) may benefit some patients
- 42. • PREVENTIVE TREATMENT: • Verapamil: • Pretreatment ECG is essential and this drug should be avoided in conjunction with betablockers. • It is given in a starting dose of 120 mg long acting daily increased to three times daily. • Lithium: • Precheck of thyroid and renal profile is necessary and lithium levels need to be monitored periodically. • Given in a starting dose of 300 mg to be gradually increased to a max of 900 mg. • Steroids: Prednisolone in a dose of 60 mg daily to start with followed by gradual tapering.
- 43. OTHER PRIMARY HEADACHE DISORDERS • Primary cough headache • Primary exercise headache • Primary headache associated with sexual activity • Primary thunderclap headache • Cold-stimulus headache • External-pressure headache • Primary stabbing headache • Nummular headache • Hypnic headache • New daily persistent headache (NDPH)
Editor's Notes
- Recurrent headache disorder manifesting in attacks lasting 4-72 hours with typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia. Recurrent attacks, lasting minutes, of unilateral fully-reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.
- The reason for singling out 1.3 Chronic migraine from types of episodic migraine is that it is impossible to distinguish the individual episodes of headache in patients with such frequent or continuous headaches. In fact, the characteristics of the headache may change not only from day to day but even within the same day. Such patients are extremely difficult to keep medication-free in order to observe the natural history of the headache. In this situation, attacks with and those without aura are both counted, as are both migraine-like and tension-type-like headaches (but not secondary headaches). Characterization of frequently recurring headache generally requires a headache diary to record information on pain and associated symptoms day-by-day for at least one month. Because tension-type-like headache is within the diagnostic criteria for 1.3 Chronic migraine, this diagnosis excludes the diagnosis of 2. Tension-type headache or its types. 4.10 New daily persistent headache may have features suggestive of 1.3 Chronic migraine. The latter disorder evolves over time from 1.1 Migraine without aura and/or 1.2 Migraine with aura; therefore, when these criteria A-C are fulfilled by headache that, unambiguously, is daily and unremitting from <24 hours after its first onset, code as 4.10 New daily persistent headache. When the manner of onset is not remembered or is otherwise uncertain, code as 1.3 Chronic migraine. The most common cause of symptoms suggestive of chronic migraine is medication overuse, as defined under 8.2 Medication-overuse headache. Around 50% of patients apparently with 1.3 Chronic migraine revert to an episodic migraine type after drug withdrawal; such patients are in a sense wrongly diagnosed as 1.3 Chronic migraine. Equally, many patients apparently overusing medication do not improve after drug withdrawal; the diagnosis of 8.2 Medication-overuse headache may be inappropriate for these (assuming that chronicity induced by drug overuse is always reversible). For these reasons, and because of the general rule to apply all relevant diagnoses, patients meeting criteria for 1.3 Chronic migraine and for 8.2 Medication-overuse headache should be coded for both. After drug withdrawal, migraine will either revert to an episodic type or remain chronic, and should be re-diagnosed accordingly; in the latter case, the diagnosis of 8.2 Medication-overuse headache may be rescinded.
- Cardiovascular disorders (stroke, myocardial infarction) Psychiatric disorders (depression, anxiety, panic disorder, bipolar disorder, personality disorders, suicide attempts) Neurologic diseases (epilepsy) Sleep conditions (insomnia, restless leg syndrome, sleep apnea, poor sleep quality and duration) Inflammatory conditions (allergic rhinitis, asthma) Chronic pain conditions (fibromyalgia)
- -acute medications are used on ≥10 d/mo for triptans, ergots, opioids, and combination analgesics -acute medications are used on ≥15 d/mo for acetaminophen and NSAIDs
- Use the least amount of the medication with the fewest side effects to gain control of the symptoms until preventive treatment can be reduced or stopped. Initiate therapy with medications that have the highest level of efficacy. Increase the dose slowly until clinical benefits are achieved without adverse events. Give each drug an adequate trial of at least 2 to 3 months. Use a long acting formulation, it will help improve compliance. Monitor the patient's headache frequency using a headache diary. Select a drug that will treat the coexistent condition and migraine. When using prophylactics, direct special attention to women who are pregnant or desire to conceive. Preventive medications may have teratogenic effects
- efficacious ones include propranolol, atenolol, and metoprolol. Beta-blockers are contraindicated in patients with asthma, chronic obstructive pulmonary disease, insulin-dependent diabetes mellitus, heart block or failure, or peripheral vascular disease. When prescribing beta-blockers, start with a low dose and titrate upward as required. Once the attacks are controlled, the medication should be tapered. Propranolol can be started in a dose of 10 mg twice daily and gradually increased to a maximum of 80-120 mg per day. Doses in Indian patients are much less than in the western population.
- Flunarizine is most commonly used for migraine prophylaxis. Flunarizine is useful as a first line prophylactic and can be started in a smaller dose of 5 mg at night and gradually increased to 10 mg daily. This will help avoid sedation. Flunarizine is to be avoided in patients with depression. Calcium-channel blockers are contraindicated in patients with hypotension, congestive heart failure, or arrhythmia.
- mg orally each night should be given at first, followed by an increase of 10 mg every week, up to 25-50 mg/day; a higher dosage may be required in the presence of comorbid depression Tricyclic drugs should be used with caution in elderly patients because of anticholinergic side effects.
- Sodium valproate, valproic acid, divalproex sodium, and topiramate have been found to be effective for migraine prophylaxis. Side effects of divalproex include nausea, alopecia, tremor, and weight gain, and their use has been associated with hepatotoxicity, particularly in children. They may also cause neural tube defects and should not be given to women who are pregnant or considering pregnancy or young women with polycystic ovarian disease (PCOD). Divalproex is started in a small dose of 250-500 mg per day and the dose is gradually increased up to 1500 mg per day with continuous monitoring for side-effects . Topiramate should be started in a small dose of 25 mg per day in adults and the dose should be gradually increased in 25 mg weekly increments to a maximum of 100 mg twice daily. Doses of topiramate for migraine in Indian patients are less than that in westerners. Topiramate should not be used in the presence of glaucoma, renal stones and tingling and numbness, diarrhea, and confusional state are some of the temporary side effects. Topiramate has the advantage of weight loss and can be used in preference to divalproex when treating obese patients.
- in different studies, and it has a very high socio-economic impact.
- Chronic tension-type headache Coded elsewhere: 4.10 New daily persistent headache. Description: A disorder evolving from frequent episodic tension-type headache, with daily or very frequent episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting hours to days, or unremitting. The pain does not worsen with routine physical activity, but may be associated with mild nausea, photophobia or phonophobia. Diagnostic criteria: Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year), fulfilling criteria B-D Lasting hours to days, or unremitting At least two of the following four characteristics: bilateral location pressing or tightening (non-pulsating) quality mild or moderate intensity not aggravated by routine physical activity such as walking or climbing stairs Both of the following: no more than one of photophobia, phonophobia or mild nausea neither moderate or severe nausea nor vomiting Not better accounted for by another ICHD-3 diagnosis1;2;3. Notes: Both 2.3 Chronic tension-type headache and 1.3 Chronic migraine require headache on 15 or more days/month. For 2.3 Chronic tension-type headache, headache must, on at least 15 days, meet criteria B-D for 2.2 Frequent episodic tension-type headache; for 1.3 Chronic migraine headache must, on at least eight days, meet criteria B-D for 1.1 Migraine without aura. A patient can therefore fulfil all criteria for both these diagnoses, for example by having headache on 25 days/month meeting migraine criteria on eight days and tension-type headache criteria on 17 days. In these cases, only the diagnosis 1.3 Chronic migraine should be given. 2.3 Chronic tension-type headache evolves over time from 2.2 Frequent episodic tension-type headache; when these criteria A-E are fulfilled by headache that, unambiguously, is daily and unremitting from less than 24 hours after its first onset, code as 4.10 New daily persistent headache. When the manner of onset is not remembered or is otherwise uncertain, code as 2.3 Chronic tension-type headache. In many uncertain cases there is overuse of medication. When this fulfils criterion B for any of the subtypes of 8.2 Medication-overuse headache and the criteria for 2.3 Chronic tension-type headache are also fulfilled, the rule is to code for both 2.3 Chronic tension-type headache and 8.2 Medication-overuse headache. After drug withdrawal, the diagnosis should be re-evaluated: not uncommonly the criteria for 2.3 Chronic tension-type headache will no longer be fulfilled, with reversion to one or other episodic type. When the disorder remains chronic after withdrawal, the diagnosis of 8.2 Medication-overuse headache may be rescinded.
- Similar to the association between migraine and psychiatric disorders, tension-type headache, especially chronic TTH, is strongly associated with GAD and MDD.110 Generalized anxiety was found to be present in 38.5%-52.5% of TTH patients.111,112 Additionally, major depression is also found frequently in patients with TTH (32.7%-36.4%).111,112 Finally, suicidal ideation may be associated with TTH disorders. In a recent study, 17.3% of TTH sufferers reported suicidal ideation.11
- Tricyclic antidepressants: Amtriptlyline has been found to be most effective. Amtriptlyline should be started on low dose (10 mg to 25 mg per day) and titrated by 10-25 mg weekly till the therapeutic effect or the side effects appear. The common side effects of the drug are dry mouth and drowsiness. Serious side effects like cardiac arrhythmias, precipitation of glaucoma, and urinary retention can occur in predisposed, especially elderly subjects. Mirtazepine: can be given in situations where amtriptlyline is either ineffective or contraindicated. Other antidepressants like SSRI and tetracyclics have been found to be not so useful. Recently, Botulinum Toxin Type A injection has been tried in CTTH with variable results. Currently, this is reserved for refractory patients. Relaxation training and biofeedback training are also helpful. Usually, preventives are continued for 6 months following which withdrawal is attempted. Upon withdrawal, some patients continue to remain headache free while others start to have headaches again. These patients usually require long-term treatment.
- Relaxation training The goal of relaxation training is to help the patient to recognize and control tension as it arises in the course of daily activities. During the training, the patient sequentially tenses and then releases specific groups of muscles throughout the body. Later stages involve relaxation by recall, association of relaxation with a cue word, and maintaining relaxation in muscles not needed for current activities [Holroyd et al. 2005]. EMG biofeedback The aim of EMG biofeedback is to help the patient to recognize and control muscle tension by providing continuous feedback about muscle activity. Sessions typically include an adaptation phase, baseline phase, training phase where feedback is provided, and a self-control phase where the patient practices controlling muscle tension without the aid of feedback [Holroyd et al. 2005]. Cognitive-behavioural therapy The aim of cognitive-behavioural therapy is to teach the patient to identify thoughts and beliefs that generate stress and aggravate headaches [Holroyd, 2002]. These thoughts are then challenged, and alternative adaptive coping self-instructions are considered. A variety of exercises may be used to challenge thoughts and beliefs, including experimenting with the adoption of another person's view of the situation, actively generating other possible views of a situation, and devising a behavioural experiment to test the validity of a particular belief
- luster headache is maximal orbitally, supraorbitally, temporally or in any combination of these sites, but may spread to other regions. During the worst attacks, the intensity of pain is excruciating. Patients are usually unable to lie down, and characteristically pace the floor. Pain usually recurs on the same side of the head during a single cluster period. Age at onset is usually 20-40 years. For unknown reasons, men are afflicted three times more often than are women. Acute attacks involve activation in the region of the posterior hypothalamic grey matter. 3.1 Cluster headache may be autosomal dominant in about 5% of cases. Some patients have been described who have both 3.1 Cluster headache and 13.1.1 Trigeminal neuralgia (sometimes referred to as cluster-tic syndrome). They should receive both diagnoses. The importance of this observation is that both conditions must be treated for the patient to become headache free.
- Verapamil: Pretreatment ECG is essential and this drug should be avoided in conjunction with betablockers. It is given in a starting dose of 120 mg long acting daily increased to three times daily. Constipation is the main side effect Steroids: Prednisolone in a dose of 60 mg daily to start with followed by gradual tapering. Normal precautions as while administering steroids.