How Can We Help?
Headache
Introduction
New onset headache is a common complaint, and should be taken very seriously – consider CT scan and other investigations, e.g. CSF examination, as appropriate – if there is:
- Worsening symptoms over weeks to months
- Abrupt onset
- Onset over the age of 50, or new onset in an HIV positive individual
- Any neurological symptoms
- Pain worse with coughing or sneezing
- Pain made worse or better by lying or sitting up (i.e. any postural component)
- Focal neurological signs
- Papilloedema
Migraine.
Diagnosis
Stereotyped usually hemicranial pain, with a preceding aura and a response to analgesics and rest in a darkened room.
Management of an acute attack:
Acute attacks of migraine respond to treatment in 60-90%, depending as much on the time at which assessment of response is made as on the drugs used. In general, although there are statistically significant advantages from using the newer agents (the tryptans), the clinical value of these quite expensive preparations is still not entirely clear. A recent narrative review[16] suggested that combination aspirin and metoclopramide is as effective as oral sumatriptan and superior to ergotamine.
Paracetamol 1g 4 hourly.
Add metoclopramide 10 mg PO or IMI 3x/day if nausea is bothersome.
Presenting later or not responding to paracetamol: ibuprofen 800 mg 3x/day.
There may be a role for standard dose opiates in a non-responding patient, but beware of contributing to the development of an addiction in patients with frequent headache – it is important to demonstrate to the patient that aggressive doses of non-opiate conventional analgesics can work.
Migraine prophylaxis:
Try amitriptyline 10 mg nocte, increasing to 25 mg nocte after a month if the lower dose is not effective. A low dose of propranolol (e.g. 20 mg 2x/d) may also work in about 30% of patients. In a recent narrative review,[17] none of the three most commonly prescribed agents (beta-blockers, tricyclics, or calcium antagonists) was demonstrated to show a benefit of more than 50% over placebo.
Reconsider the diagnosis in both acute and chronic phase if not settling quite promptly.
Perspectives –diagnosing migraine.
Diagnosing the cause of a headache is predominantly based on the history. Be particularly careful of calling any new onset headache a migraine, although there has to be a first time… Always think of intracerebral mass lesions or recurrent bleeding (subarachnoid warning bleeds). However, it is also useful to consider features that may distinguish migraine from a tension-type headache[18]: nausea had a LR+ of 19.2, photophobia 5.2, and a headache that was worse with activity and a unilateral headache both had a LR of 3.7.
This systematic review demonstrated that certain features are very powerful at differentiating between the two: a patient with nausea, photophobia and unilateral headache is very unlikely to have a tension headache, and very likely to have migraine. The POUNDing criteria synthesize this[19] (pulsatile, duration 4-72 hours, unilateral, nausea, disabling) If 4 or more criteria are met, the LR+ is 5.8, if 2 or less are found LR is 0.45 and with 3 features the LR is 1 (for ‘definite’ migraine)
Headaches other than migraine
An umbrella term which covers many of these conditions is ‘chronic daily headache[20]’ which is defined as headache more than 15 days each month for more than three months. The common causes for this are tension headache and medication overuse headache; less common possibilities are transformed migraine (daily headaches that started off as typical migraines), new daily persistent headache, hemicrania continua, cluster headache, paroxysmal hemicrania (pain lasts < 25 min per episode) , hypnic headache (only during sleep), and SUNCT (short-lasting (<2 min) unilateral neuralgiform headache with conjunctival injection and tearing). Do not forget sinus headaches (pain worse on wakening and relieved by getting up, and the rare syndrome of intracranial hypotension and CSF leak[21] (headache relieved by lying down, associated with Marfan, Ehlers-Danlos and polycystic kidney disease).
Cluster headache
These are intense throbbing unilateral headaches usually around one eye but sometimes into the temporal area, which affect males predominantly and come on an hour or so after falling asleep. They may recur nightly for a week or more, and then can go away for months on end. There may be a sensation of nasal stuffiness, and a watery red eye. Prophylaxis is with amitriptyline, and intranasal lignocaine may abort the attack, as may inhalation of 100% oxygen, or the use of the tryptans such as sumatriptan.
Tension headache
This is characteristically not a ‘new’ headache.
- Bilateral, dull
- Associated tenderness of neck muscles
- Often worse on working days than on weekends
- Present all day, day in and day out.
- Minimal relief from analgesics
- Often identifiable societal or family stressors.
Management is with reassurance and explanation. Very low doses of tricyclics (e.g. amitriptyline 10-25 mg nocte) may be of value.
To add to the confusion of busy clinicians, a relatively new (or re-vamped) hypothesis[22] suggests that tension headache and migraine may share the same pathophysiology, with tension headache being a forme fruste of migraine. (The so-called convergence hypothesis.)
Analgesic abuse headache
It is important to consider, and take a history to exclude, the superficially similar analgesic abuse headache. The key difference is that there is some relief from simple analgesics, but pain tablets are being taken several times a day, every day. The remedy for this is again explanation, but then also to completely stop all analgesics. Symptoms usually subside in a few days if your diagnosis was correct, with reversion to less troublesome previous headache patterns. Some authors have suggested that a 5 day course of prednisone (e.g. 1 mg/kg/day) may help wean, but the evidence of efficacy is scanty[23].
Trigeminal neuralgia and other facial pain syndromes
Trigeminal neuralgia (tic douloureux) sometimes presents with a complaint of a headache, but on careful questioning is quite clearly a facial pain. Pain is intense, but short lived and recurrent. There may be a precipitant (eating, cleaning teeth, shaving).
Trigeminal neuropathy is a longer-lasting neuropathic pain.
Management
Both illnesses will respond to titrated doses of tricyclics or carbamazepine, but trigeminal neuropathy warrants a particularly careful look for an underlying cause.