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
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%+)
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Tension – type
Migraine
Stabbing
Exertional
Cluster
69
16
2
1
0.1
• Due to something else
(<1%)
• Systemic infection
• Head injury
• Vascular / bleeding
63
4
1
• Brain tumour
0.1
Headache diagnosis
• almost entirely on the patients story
• tests, scans etc rarely helpful.
Headache: history
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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-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
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 - 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
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
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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
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
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
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Stabbing headaches
After head injury / head surgery
Sexual headaches
Altitude sickness
Treatment
Explanation, set realistic objectives
Treatment of
the attack
Treatment to reduce
attack frequency
Lifestyle change
Treatment of the attack
1
2
3
General pain relievers
Migraine-specific treatments
- triptans and ergots
Cluster specific treatment
- oxygen
- triptans
General pain relievers : migraine,
tension
aspirin
Fast?
✔✔
codeine
tramadol
✔
✔
✔✔
Safe?
OK for
long term?
paracetamol ibuprofen
✖
✔✔
✖
✖✖✖
Additives : metoclopramide (nausea)
caffeine
Not suitable : dextropropoxyphene “Doloxene; Di-Gesic”
morphine, pethidine
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
Poor
amitriptyline
ibuprofen
Cluster preventers - balance of
effectiveness and safety /
tolerability
Effectiveness
Tolerability / safety
Good
Fair
Good
verapamil
Fair
topiramate
Poor
methysergide
steroids
Poor
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 tensiontype 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/