Pain: Headaches

PHAR 3330
October 18, 2021

Kiwi WY Sun
kiwisun@cuhk.edu.hk
 Learning Objectives
By the end of this lecture you should be able to:

Identify the types of headache

Identify the risk factors

Recommend appropriate OTC treatment options

Provide patient-care counselling

Headaches
Possible causes
n r
t n m o

ca t
P S Y uh 0 I 0
gi
ro b le m
p
d s sure
h i gon pl l
00 ne i

m ed
- i n d u ad .
Classification of headaches
Primary headaches (no clear underlying causative pathology):
Tension headache
Migraine headache
Cluster headache

Secondary headaches (identifiable abnormality):

Injury/trauma
Vascular disorder
Substance use or withdrawal
Medication-overuse
Infection
Psychiatric disorder
General questions to ask the patient
Location of pain
Onset
This episode
Previous onset
Frequency
Specific pattern
Specific time
Severity of pain
0-10 scale
Triggers
Specific foods
Stress
Associated symptoms NIV diarrhoea / constipation .
 Location of pain

Rutter et al Community pharmacy, 5ed, Fig5.1.

Tension headache > 80% in community

The most common type of headache in adults and children

Clinical features:
Usually bilateral
Mild to moderate intensity of pain
Not worsened by physical activity
Tightening sensation and pressure across the front head
Dull pain
May arise from the neck or shoulder
May be agitated by noise and/or flashing light
Usually not associated with n/v
Tension headache
Acute tension headache:
Usually self-limiting
Last for a few hours to days

Chronic tension headache:

Average occur >= 15 days per month can be on and Off .

Last for > 3 months

Risk factors:
Stress
Emotional upset
Adults> children
Migraine 4&q¥¥Éq
female > male .

General clinical features:

Severe pain
Unilateral location
Throbbing in nature like a hammer hitting your head .

Aggravated by movement
Relief when lying down
sound soft music won't help
Photophobia and phonophobia ,
even .

Associated with n/v

Last for a few hours
Usually up to 72 hrs
Migraine
Two types of migraine:
With aura (~25%) the sense of c. this coming
Prodromal phase (~ an hour) ¥n¥5:b
Alternations of vision before the attack starts
Flashing lights (Photopsia)
Tingling/numbness
One side of the body
Lips/face/fingers
Dysphasia don't want to eat
After prodromal phase, the headache usually follows
L Some have delay )

Without aura (~75%) no warning sx .

No prodromal phase
 a
Migraine and stroke relative
higher

stroke
risk i

OCP .
A

thromboembolism .

T risk of stroke it

migraine with aura .

→ should refer to
an .
discuss with

c.
'

high risk of stroke .

BMJ 2009;339:b3914
Suggested pathophysiology of migraine
Neurovascular origin
Brain and blood vessels
Vascular dysfunction
Transient intracranial vasoconstriction
Migraine occurs from rebound vasodilation
Disorder of sensory processing
5-HT
Catecholamines
Histamine
Prostaglandins
Neuropeptides
Calcitonin gene-related peptide (CGRP)

Lancet Neurol 2018; 17: 174 82

Episodic vs chronic migraine
Episodic migraine:
< 15 days per month

Chronic migraine: baseline

>= 15 days per month gas
With superimposed migraine on >= 8 days per month for > 3 months
write down the
Majority of Ptx with chronic migraine
days of sx on .
a
diary
Background headache + migraine attacks a clear
so
they have
record i
Triggers
Risk factors:

Female 3x > male

Reproductive age
Oestrogen
Before and after menstruation
Acute management
Aims:
Stop the attack of migraine
Reduce the severity

Options:
Avoidance of the triggers
Simple analgesics an option
just
}
.

Aspirin so high dose

-

Soluble 900 mg PO STAT

Paracetamol 1 tab 500mg
:
if severe
. :3 tabs at Igo is ok ,

1000-1500 mg PO STAT
NSAID
Ibuprofen 400-600 mg PO STAT

Note: Opioids should be avoided- exacerbate nausea & reduce GI motility

codeine OTC .

not in HK .
 Antiemetics:
Metoclopramide- P1S1S3
5-10 mg PO TDS
can also used to
Domperidone- P1S1S3 - induce lactation

10-20 mg PO up to QID in nighdose and special

regimen
Prochlorperazine- P1S1S3
.

5-10 mg PO TDS

Triptans (2nd line)- P1S1S3

Constrict cranial vessels by acting selectively at 5-HT1B/1D receptors
during the
Most effective if taken at the beginning of the headache 2hrs1 take
i
: studies Not during aura short lived
, .

NSAIDs
,
show that nd dose- at least 2 hrs after the 1st dose (if the symptoms reoccurs) paracetamol
there's no
2 ,

↳
use Do not take the 2nd dose if no response to the 1st dose
Sumatriptan, Zolmitriptan, Eletriptan PO
Similar efficacy
Triptans: ADR & DDI stay home avoid driving .

ADRs:
n/v
Dizziness
Flushing
Fatigue
Tingling
Pain in other part of the body

DDI:
MAOI
Within the past 2 weeks
Ergot
wort
 good
'
t cause any
.

Analgesic + sympathomimetic + relaxant: believed by FDA

Migaphen cap (2nd line)- P1S1S3
Paracetamol (325 mg) + isometheptene (65 mg) + dichloralphenazone (100 mg)
Unapproved by FDA in 2018
= Midrin in UK
Migraine: 2 cap STAT, 1 cap q1h prn, max. 5 cap per day
Tension headache: 1-2 cap q4h prn, max. 8 cap per day
Prevention no standard
guideline ,
Aims: trial for 8 wks

Reduce frequency, duration or severity of attacks low dose .

Recommend to Ptx who have 2-3 severe migraines per month

Prophylactic agents should be trialled for 8-12 weeks to assess efficacy

Start at low dose and gradually up-titrate

Options:- P1S1S3
BB (e.g. propranolol)
TCA (e.g. amitriptyline)
Anticonvulsants (e.g. valproate & topiramate)
Botulinum toxin type A (PREEMPT trials)
Erenumab & Galcanezumab (CGRP inhibitors- injection)
Migraine medications in pregnant Ptx
! Change of
1
hormone
Reduce frequency and severity of migraine attacks in the 1st trimester .

Migraine (with aura) is a risk factor for pre-eclampsia, cerebral venous thrombosis and
stroke during pregnancy

Management in pregnancy:
Lifestyle and nonpharmacological approaches (good evidence)
Relaxation training
Exercise
Sufficient fluid intake

1st- paracetamol +/- metoclopramide

2nd- sumatriptan : most evidence in the
'

3 trip tins .

Prevention- propranolol
- low dose TCA
Migraine medications in lactating Ptx
Many women experience migraine recurrence within 1 mth of delivery

Management in breastfeeding:
Lifestyle and nonpharmacological approaches
1st- paracetamol/ NSAIDs (except aspirin)
2nd- sumatriptan
Low bioavailability to an infant
Best studied triptan in breastfeeding
Eletriptan has the highest protein binding of the triptans → breast milk → baby

Prevention- propranolol
- low dose TCA
Migraine medications: acute management
Migraine medications: prevention
Cluster headache aka orbital headache .

Neurological disorder- rare

Clinical features:
Unilateral orbital pain (aching or sharp pain)
Typically around the eye extreme .

Eye watering
Nasal congestion
Swelling around the eye https://myhealth.alberta.ca/Health/Pages/condition
s.aspx?hwid=tp10862&lang=en-ca
Other associated symptoms
Facial flushing
Sweating
Sleep disturbance
Last for minutes to hours
Can experience 1-3 attacks per day
 panada is not likely to help .

Treatment option- referral:

Triptans
CCBs to control the vasoconstriction .
 the role :
to rule out other
possibilities .

Conditions not to be mixed up:

Sinusitis
Loss of smell
Pain behind the eye
Other symptoms of cold/flu infections
Relieved by nasal decongestant
Eye strain
Less intensity
Also experience frontal aching headache
Relieved by eye relaxation methods
Glaucoma
Cornea looks cloudy
No nasal congestion
Haemorrhage
n/v
Head injury
Which type of headache?
Patient A
30 yr-old female
Frontal headache, dull pain and muscle ache
Started 3 days ago hrs days
- .

Feeling nauseous after smelling a durian

Regular med: Lisinopril 10 mg QD for HTN

Which type of headache is it? tension

What treatment option is the most appropriate? panadol 2-3 tabs STAT
Max :
8 tab ,
Which type of headache?
Patient B
27 yr-old female
Throbbing dull pain at the left frontal head
÷m_jÉ&Égy9b_tF¥gson% caffeine ,

No head injury

)
Has been taking combined oral contraceptive pills for a year
Headache is triggered by flashing lights ( aura ) ask mom hx .

Blurred vision migraine ① paracetamol frequency

{
. - ,

Started 3 hours ago IKE ② NSAID .

ibuprofen 400mg -
PO
caffeine
.

for better ③
.

.
paracetamol 2tabS .

efficacy
migraine → ith aura together ?
Which type of headache is it? yes .
has 2in 1 product too .

What treatment option(s) can you offer? TAIN has 1-

ray .
Treat or Refer?
Patient C
11 yr-old male
Mild- moderate dull pain across the frontal head
No fever
Started 3 hours ago
No other known medical conditions or allergies

Which type of headache is it? Tension .

← if really can confirm .

/ internal bleeding 1
How would you deal with this case? I
e. or any head
injury
family hx .

Once confirm
It paracetamol
Treat or Refer?
Patient D
12 yr-old male
Severe pain at the right eye and surrounding area
Stiff neck
Fever
Feeling nauseous
Started this morning

How would you deal with this case? refer .

sx of meningitis .
Classification of headaches
Primary headaches (no clear underlying causative pathology):
Tension headache
Migraine headache
Cluster headache

Secondary headaches (identifiable abnormality):

Injury/trauma
Vascular disorder
Substance use or withdrawal
Medication-overuse
Infection
Psychiatric disorder
Alarm symptoms for referral
Headache in children (<12-yr-old) with fever, stiff neck, skin rash
Meningitis
Duration > 2 weeks
Severe headache for > half a day
Headache unresponsive to OTC analgesic
Check dosage
Recent head injury/trauma
Raised intracranial pressure/ haemorrhage
New onset of headache in mid-aged or elderly
Identified underlying causes
Infections
Fever
Comorbidity disorders
Frequent headaches requiring prophylactic Tx
Medication overuse headache (MOH)
A type of chronic tension headache due to medication overuse for pain
PO analgesic agent(s) for >= 10 days per month
Example: Patient X has been taking paracetamol 500 mg QD for 2 months
not related to dose but

Analgesic medications include: the duration .

NSAIDs
Paracetamol
Triptans
Opioids
Ergots
Single agent or any combination of the above
Management of MOH
Identify the agent, frequency, duration of use
Withdrawal of the analgesic agent(s)
Need careful support in patient
µ
.

Refer to pain clinic if needed

Stop abruptly vs gradually
May take months to resolve the MOH
CAM for headaches
Magnesium (Grade C- possible effective)
Regulates muscle tone, vascular tone, neuronal hyper-excitability etc.
low bioavailability
Higher absorption (organic): magnesium- citrate, - chloride, - amino acid chelate, - glycinate
Lower absorption (inorganic): magnesium oxide
2
bowel issue &

Symptoms of hypomagnesaemia: waste of money

Lethargy, n/v, loss of appetite 1 Pt taking

longterm PPI

Indications of Mg salts:
Migraine in adults
Menstrual migraine
Nocturnal leg cramps
Anxiety & stress
50- 600 mg elemental Mg2+ daily in divided doses at least Bb if not TDs .

Headache 2018 Feb;58(2):199-209

CAM for headaches
ADR of Mg salts:
GI upsets
Diarrhoea
n/v
Caution: Ptx with CKD and cardiac problems

DDI:
Bisphosphonates
CCBs
Tetracycline
Fluoroquinolone
Aminoglycoside

Separate dosing for at least 2 hours '

I
affects absorption
Ptx education and counselling
Educate about condition
Enable Ptx to participate in their own management
Provide treatment options
Non-opioid analgesics:
Take sufficient dose early in the attack
Limit use to < 15 days per month
Triptans:
Take when headache is beginning to develop
Not too earlier during aura, or too late
Limit use to prevent the risk of MOH
If acute Tx is needed > 4 days per month
Referral for prophylaxis
Educate on administration, ADRs etc.
Headache diary to record the frequency, duration, severity etc.
Questions

39