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%+)

Tension type
Migraine
Stabbing
Exertional
Cluster

69
16
2
1
0.1

Due to something else

(<1%)
Systemic infection
Head injury
Vascular / bleeding
Brain tumour

63
4
1
0.1

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

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?

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

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

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?

Safe?
OK for
long term?

paracetamol ibuprofen

codeine

tramadol

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/