This document summarizes headache diagnosis and treatment. It begins by explaining that in most cases, headaches are not caused by brain damage but by issues with brain membranes and blood vessels. It then discusses the most common types of primary headaches like tension, migraine, and cluster headaches. The document outlines diagnosis methods and treatments for different headaches, including general pain relievers, triptans, ergots, and preventative medications. It concludes by discussing non-drug therapies and new research into non-drug electrical therapy, new drug approaches, and potential "vaccinations" for migraine prevention.

1. Headache
diagnosis and treatment :
now and the future
Paul Rolan MBBS MD FRACP FFPM DCPSA
Professor of Clinical Pharmacology
Senior Consultant, Pain Management Unit, RAH

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

4. 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 tumour 0.1

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

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?

7. Pattern recognition
pick the odd one out

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

9. 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)

13. What happens during a migraine?

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

16. Migrainous Aura

17. Migrainous Aura

18. Migrainous Aura

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

21. Cluster Headache

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

24. Treatment
Explanation, set realistic objectives
Lifestyle change
Treatment of
the attack
Treatment to reduce
attack frequency

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

30. Main migraine preventers
Effectiveness
Tolerability / safety Good Fair Poor
Good propranolol verapamil
Botox
Fair amitriptyline
topiramate
valproate
pizotifen
ibuprofen
Poor methysergide

31. Tension preventers
Effectiveness
Tolerability / safety Good Fair Poor
Good
Fair amitriptyline ibuprofen
Poor

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

34. In the pipeline

35. In the pipeline
• “vaccination” for migraine
• new classes of drugs

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

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