differential dx of headache
Haemorrhage
Eclampsia (can occur post partum)
Arterial (dissections / temporal arteritis)
DVT of the brain = cavernous venous thrombosis
Tumour or trauma
Infection
Eye (glaucoma)
MIGRAINES
Suspect Aura in those patients with or without headache who present with neurological symptoms that are;
Fully reversible
Occur gradually over at least 5 mins
Last for 5-60mins
MIGRAINES
Diagnose migraine with aura with or without headache with one or more of the following typical aura sx (which meets when to sspect aura)
Visual sx
+ve = flickering lights
-ve = loss of vision partially
Sensory sx
+ve = pins and needs
-ve = numbness
speech disturbance
What are the diagnostic features of a migraine?
Headache lasting 4–72 hours
At least two of: unilateral location pulsating quality moderate to severe pain intensity worsened by routine physical activity
At least one of:
nausea and/or vomiting
photophobia and phonophobia
MIGRAINE:
- Acute Treatment
- Prophylactic Treatment
- Acute
- NSAID + Triptan or Paracetamol + Triptan
- Aspirin 900mg
- Metoclopramide
- Sumpatriptan - Prophylactic (consider if migraines 2-4 per month)
- Topiramate (risk of malformations and impair effect of OCP)
- Propranolol
- Amitryptalline
- Pizofiten (Sandamigran)
Not for gabapentin
When to refer to specialist ?
Refer patients with migraine to an expert when:
–> neurological symptoms are prolonged
–> the usual headache pattern deteriorates suddenly
–> they need acute treatment (analgesics or triptans) for more than 8 to 10 days per month and do not respond to prophylaxis in the usual dose range
–> they often need emergency department or hospital treatment or have to take days off work due to migraine
–> they have isolated aura without headache
the diagnosis is uncertain.
–> Send patients with thunderclap headache (even if they routinely have migraines) for urgent assessment in an emergency department.
(etg)
- Dose of sumatriptan that can be given?
2. Can it be given on SSRI’s or SNRI’s?
- –> sumatriptan 20 mg intranasally. Wait at least 2 hours before repeating the dose if needed (maximum dose 40 mg in 24 hours)
OR
sumatriptan 50 to 100 mg orally. Wait at least 2 hours before repeating the dose if needed (maximum dose 300 mg in 24 hours)
- Yes but explain serotonin toxicity
e. g. agitation, confusion, rapid heart rate, dilated pupils, muscle twitching or rigidity, sweating, diarrhoea, headache, shivering), despite its rarity.
Cluster headaches
1/ acute treatment
2/prevention
1/ sumatriptan 20mg intranasally
2/ verapamil
(ref; etg)