Whats new in headache Generally Im very brave, only today I happen to have a headache Tweedledum

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Whats new in headache? Generally Im very
brave, only today I happen to have a headache
Tweedledum
Stuart Weatherby
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Whats new in headache?

• Increasing awareness of the burden of disability
• Easy way to recognise migraine
• Some new treatments and some old treatments
  (migraine)
• Some info on other headaches

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• WHO
• Headache generates a substantial disability
  burden and should be classified amongst major
  public health disorders
• But there is lack of public and professional
  awareness of the..impact on individual sufferers,
  their carers, family and colleagues, and on
  society.

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Leading causes of years lived with disability WHO
figures 2000
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What is the room for improvement in Headache?

• Only 29 of migraine sufferers say they are
  satisfied with their usual headache treatment
• In USA and UK only 2/3 of migraine correctly
  diagnosed
• Anxiety and depression go with the
  territory-Depression is three times more common
  in people with migraine or severe headaches than
  in healthy individuals.

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Recognising migraine- the easy way. ID Migraine.
3 questions

• ID Migraine Neurology. 2003 Aug 1261(3)375-82
• Has a headache limited your activities for a day
  or more in the last three months?
• Are you nauseated or sick to your stomach when
  you have a headache?
• Does light bother you when you have a headache?
• Positive 2 of the 3, developed as the best of a
  9 question study
• Sensitivity of 0.81, a specificity of 0.75 and
  positive predictive value of 0.93

Migraine
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To scan or not to scan?

• US Headache consortium review from 1966-1998
• Serious abnormality in lt0.5 of pts without
  abnormal signs (if migraine/TTH/ or chronic
  headache and no neurological signs)
• Recommendations
• Patients with no neurological signs
• Abnormality on scan no greater than chance
• Patients with neurological signs
• Scan them all

US headache consortium
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Stroke Migraine and COCP

• MWOA RR 1.8
• MWA RR 2.3
• Migraine and COCP RR 8.7
• Avoid in COCP in MWA, or MWOA and other risk
  factors

Migraine
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Migraine Treatments
Migraine
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Triptans- drug interactions

• If on MOA- avoid Suma, Zolmi, Riza
• Propanolol increases Riza levels so give ½ dose
• Cimetidine increases Zolmi so use half dose
• Some are cytochr P450, others via MOA
• Shouldnt be used in those with or sig. at risk
  of cardiac ischaemia
• Dont use in basilar migraine

Migraine
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Topiramate

• MIGR 001 USA- N469
• Arch Neurol 2004
• MIGR 002 US and Canada N 468 JAMA 2004
• MIGR 003 Europe N575
• J Neurol 2004
• 50 experienced a 50 reduction in migraine
• Weight loss 2-2.5 on 50mg
• . 3-4 on 100mg

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Co-enzyme Q10

• Neurology. 2005 Feb 2264(4)713-5.
• Responder-rate for attack frequency was 14.4 for
  placebo and 47.6 for CoQ10

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Acupuncture for idiopathic headache (Cochrane
Review)

• Reviewers' conclusions Overall, the existing
  evidence supports the value of acupuncture for
  the treatment of idiopathic headaches.
• However, not fully convincing.
• 2005 The proportion of responders (reduction in
  headache days by at least 50) was 51 in the
  acupuncture group, 53 in the sham acupuncture
  group, and 15 in the waiting list group.

Migraine
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Psychological therapies for the management of
chronic and recurrent pain in children and
adolescents (Cochrane Review)

• Reviewers' conclusions There is very good
  evidence that psychological treatments,
  principally relaxation and cognitive behavioural
  therapy, are effective in reducing the severity
  and frequency of chronic headache in children and
  adolescents.
• There is at present no evidence for the
  effectiveness of psychological therapies in
  attenuating pain in conditions other than
  headache, and little evidence for the
  effectiveness of psychological therapies in
  improving non-pain outcomes.

Migraine
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Other headaches short lasting headaches
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BASH guidelines- Migraine - Preventive Treatment

• Try adequate doses for about 6 months
• First choice Betablockers (Propranolol,
  Atenolol), (Amitriptyline, Nortriptyline)
• Second choice Antiepileptic drugs (Valproate
  care in females, Topiramate)

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BASH guidelines

• Third choice Gabapentin, Methysergide,
  Betablocker and Amitryptiline together
• Others, pizotifen, verapamil, SSRIs, riboflavin,
  coenzyme Q10, magnesium
• Special cases Menstrual migraine NSAIDs,
  continuous contraceptive pill,
• naratriptan, frovatriptan
• Exercise induced betablockers, indomethacin

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Migraine Prophylactic Drugs 1

• First-line
• Beta-blockers (atenolol,metoprolol, propranolol,
  bisoprolol) if not contra-indicated
• Amitriptyline when migraine co-exists with
• TTH
• Another chronic pain condition
• Disturbed sleep
• Depression

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Migraine Prophylactic Drugs 2

• Second-line
• Sodium valproate
• Topiramate
• Evidence for sodium valproate is reasonable and
  clinical usage is extensive
• Evidence for topiramate is very good but clinical
  usage is as yet limited

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Migraine Prophylactic Drugs 3

• Third-line
• Gabapentin
• Methysergide
• Beta-blockers and amitriptyline (in combination)

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Migraine Prophylactic drugs 4

• Other options (limited efficacy)
• Pizotifen
• Verapamil
• SSRIs

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Migraine Menstrual attacks

• Perimenstrual prophylaxis
• Non-hormonal
• Mefenamic acid - first-line in migraine occurring
  with menorrhagia and/or dysmenorrhoea
• Oestrogen
• If the women has an intact uterus and is
  menstruating regularly, no progestogens are
  necessary
• Combined oral contraceptives
• Migraine without aura in pill-free interval may
  resolve with a more oestrogen-dominant pill
• Not recommended for women with migraine with aura

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MigraineHRT

• Migraine and hormone replacement therapy
• The menopause itself commonly exacerbates
  migraine
• Symptoms can be relieved with HRT
• No evidence that risk of stroke is elevated or
  reduced by use of HRT in women with migraine
• Some women on HRT find migraine worsens
• Often solved by reducing dose and/or changing to
  non-oral formulation

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Financial Costs American Productivity Audit (APA)
Largest national database linking health
conditions to workplace costs (30,000
individuals) The cost of headache in the U.S. is
23.7 billion Headache is among the top 5 most
expensive health conditions in the workforce
In UK 25 million days of missed work or
school each year