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%+) • Due to something else

(<1%)
• Tension – type 69
• Systemic infection 63
• Migraine 16 • Head injury 4
• Stabbing 2 • Vascular / bleeding 1
• Exertional 1 • Brain tumour 0.1
• Cluster 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 Treatment to reduce

the attack attack frequency

Lifestyle change
 Treatment of the attack
1 General pain relievers
2 Migraine-specific treatments
- triptans and ergots
3 Cluster specific treatment
- oxygen
- triptans
 General pain relievers : migraine,
tension
aspirin paracetamol ibuprofen codeine tramadol

Fast? ✔✔ ✔ ✔
Safe? ✔✔
OK for ✖ ✔✔ ✖ ✖✖✖
long term?

Additives : metoclopramide (nausea)

caffeine

Not suitable : dextropropoxyphene “Doloxene; Di-Gesic”

morphine, pethidine
 Triptans : Imigran, Zomig,
Naramig, Maxalt, Relpax
FOR • AGAINST
• can be very • feel strange, chest
effective : pain
migraine, cluster • expensive, small
(NOT tension) supply
• tablets, wafers, • overuse makes
nasal spray, headaches more
injection frequent
• constrict blood
vessels
 Ergots : migraine, cluster

FOR • AGAINST
• can be very • hard to get
effective when • overuse causes
others fail poor circulation
• nasal spray, and more
suppository headache
injection • 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 pizotifen

topiramate ibuprofen
valproate

Poor methysergide
 Tension preventers

Effectiveness

Tolerability / safety Good Fair Poor

Good

Fair amitriptyline ibuprofen

Poor
 Cluster preventers - balance of
effectiveness and safety /
tolerability
Effectiveness

Tolerability / safety Good Fair Poor

Good verapamil

Fair topiramate

Poor methysergide lithium

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