HEADACHE
What you need to know
Age Adult, child
Duration
Nature and site of pain
Frequency and timing
Previous history Fits, faints, blackouts and
migraine
Associated symptoms (Nausea, vomiting and
photophobia )
Precipitating factors (Foods, alcohol, stress and
hormonal)
Recent trauma or injury
Falls
Migraine
The peak onset for a person to have their first attack is
in adolescence or as a young adult. Migraines are
rare over the age of 50 and anyone in this age group
presenting for the first time with migraine-like symptoms
should be referred
There are two common types of migraine:
Migraine with aura is often associated with alterations in
vision before an attack starts the so-called prodromal
phase.
migraine without aura, there is no prodromal phase
Women who get migraine with aura, or particularly
severe migraine without aura, should not take the
combined contraceptive pill, patch or ring, because
of an increased risk of stroke.
International Headache Society’s
diagnostic pointers for migraine
Migraine without aura (common migraine)
Headache has at least two of the following four
characteristics
1.Unilateral location
2. Pulsating quality
3. Moderate or severe pain intensity
4. Aggravation by, or causing avoidance of, routine
physical activity
During headache at least one of the following
symptoms:
1. Nausea and/or vomiting
2. Photophobia (aversion to light) and phonophobia
(aversion to noise)
Migraine with aura (classic migraine) One or more of
the following fully reversible aura symptoms:
1. Visual
2. Sensory
3. Speech and/or language
4. Motor
5. Brainstem
6. Retinal
At least two of the following four characteristics:
1. At least one aura symptom spreads gradually
over≥5 min, and/or two or more symptoms occur in
succession.
2. Each individual aura symptom lasts 5–60 min.
3. At least one aura symptom is unilateral.
4. The aura is accompanied, or followed within 60
min, by headache.
Tension-type headache
These headaches are most often related to upset or
stress.
recurrent episodes of headache that are usually bilateral
and have a pressing or tightening quality (non-pulsating)
that is mild to moderate in intensity.
is not aggravated by routine physical activity such as
walking or climbing stairs and
is not associated with nausea or vomiting or
photophobia or phonophobia
Chronic tension-type
headache
The term chronic tension-type headache is used if the headache
occurs on 15 days or more per month, on average, and lasts for
more than 3 months at a time
These types of headache are usually seen in adults (mean age
of 40 years), but they are also sometimes seen in children and in
the very old.
In some cases, it is possible that frequent use of simple
analgesics, migraine treatments or combinations containing
codeine are causing or aggravating chronic headache.
Any frequent headache needs referral to the GP surgery for
assessment.
Medication overuse
headache
Develops or worsens with frequent use of any drug treatment for
pain in people who have tension-type headache or migraine.
It has also been identified in people taking analgesics for other
painful conditions.
It is most commonly seen when triptans, opioids, ergots or
combination analgesia have been taken for 10 days per month or
more and is sometimes seen if paracetamol, aspirin or NSAID
taken on 15 days per month or more.
The main treatment is stopping the analgesia, with careful support
and encouragement. It may take 2 months to resolve.
Cluster headaches
(migrainous neuralgia)
A typical pattern would be daily episodes of pain over 2–3
months, after which there is a remission for anything up to 2
years.
In typical cases the headache commonly wakes the person
from sleep within 2 hr of going to sleep
Each episode of pain can last from 15 min to 3h,and the pain
is usually experienced on one side of the head
It is often accompanied by a painful, watering eye and a
watering or blocked nostril on the same side as the pain
It requires referral as sumatriptan which is the DOC should be
given by prescription.
Sinusitis
Sinusitis may complicate a respiratory viral infection (e.g.
cold) or allergy (e.g. hay fever), which causes inflammation
and swelling of the mucosal lining of the sinuses
The pain may be felt behind and around the eye, or over the
cheek, with radiation over the forehead and often only one
side is affected.
It is typically worse on bending forwards or lying down, the
pain is dull in nature.
A course of decongestants could be tried but if treatment
failure occurs referral to the GP for possible antibiotic therapy
would be needed.
Temporal arteritis
Usually occurs in people over the age of 60 when the
arteries that run through the temples become inflamed.
However only about a half of patients have scalp
tenderness, and these signs are not always present.
should be referred immediately as damage to the retinal
blood supply can cause blindness
It is a curable disease,if diagnosis is made early.
Treatment usually involves high-dose oral corticosteroids.
When to refer
Headache associated with injury/trauma because bruising
or haemorrhage mayoccur,causing arise in intracranial
pressure.
Headache associated with high temperature (>38◦C)
Severe headache of more than 4 h duration
Suspected adverse drug reaction
Headache in children under 12 years
Severe occipital headache (across the back of the head)
Headache that is worse in the morning and then
improves
Associated drowsiness, unsteadiness, visual
disturbances or vomiting
Neck stiffness
Frequent migraines suggesting need for
prophylactic treatment
Frequent and persistent headaches
If the headache does not respond to OTC
analgesics within a day, referral is advisable.
MANAGEMENT
Paracetamol
Has analgesic and antipyretic
effects but little or no anti
inflammatory action.
It is less irritating to the stomach
can be given to children from 2 to
3 months old
effectiveness in the management
of migraine is limited.
Can cause liver toxicity in
overdose
Ibuprofen
has analgesic, anti-
inflammatory and antipyretic
activities
causes less irritation and
damage to the stomach than
does aspirin.
Dose for analgesic activity is
200–400 mg and that for
anti-inflammatory action
300–600 mg.
Ibuprofen
The maximum daily dose
allowable for OTC use is
1200 mg
Ibuprofen tablets or
capsules should not be
given to children under 12
years.
Ibuprofen suspension 100
mg in 5 ml is available
OTC
Ibuprofen, like other NSAIDs,can be irritating to the
stomach,causing indigestion, nausea and
diarrhoea
GI bleeding can also occur
This bleeding effect is reversible within 24 h of
stopping the drug.
Ibuprofen seems to have little or no effect on whole
blood clotting or prothrombin time,but it is still not
advised for patients taking anticoagulant
medication
best avoided in patients with congestive heart
failure or renal impairment.
They should be avoided in pregnancy, particularly
during the third trimester.
Breastfeeding mothers may safely take ibuprofen
Drug interaction with lithium.
NSAIDs are best avoided in aspirin-sensitive
patients and should be used with caution in people
with asthma.
Aspirin
Aspirin is analgesic, antipyretic and
also anti-inflammatory if given in
doses of 600–900mg three to four
times daily.
It should not be given to children
under 16 years
It should not be used for gout or
where there is history of gout.
Cause Gastric irritation
can cause GI bleeding and
hypersensitivity
Not recommended during pregnancy
Codeine & Dihydrocodeine
narcotic analgesic
commonlyfoundincombination
products with aspirin,
paracetamol or both
Constipation is a well
recognised side effect
should only be used in children
over 12 years old
Codeine should also not be
used by breastfeeding mothers
CAFFEINE
• IS INCLUDED IN SOME
COMBINATION ANALGESIC
PRODUCTS TO PRODUCE
WAKEFULNESS AND
INCREASED MENTAL ACTIVITY.
• BEST AVOIDED NEAR BEDTIME
BECAUSE OF THEIR
STIMULANT AND DIURETIC
EFFECT.
• INCREASES THE
EFFECTIVENESS OF
ANALGESICS
Sumatriptan
A selective serotonin receptor
agonists. It works by narrowing
blood vessels in the head, stopping
pain signals from being sent to the
brain, and blocking the release of
certain natural substances that
cause pain, nausea, and other
symptoms of migraine.
50 mg tablets can be used OTC for
acute relief of migraine with or
without aura
used by people aged between 18
and 65 years
A 50 mg tablet is taken as soon as possible after the migraine
headache starts.
A second dose can be taken at least 2 h after the first if
symptoms come back.
A second dose should be taken only if the headache
responded to the first dose.
Caution
People with three or more of the following
cardiovascular risk factors are not suitable for OTC
sumatriptan:
Men aged over 40 years
post-menopausal women
people with hypercholesterolemia
Regular smokers (10 or more daily)
Obese people with body mass index of more than
30 kg/m2
Those with diabetes; or those with a family history
of early heart disease
Either father or brother had a heart attack or
angina before the age of 55 years or mother or
sister had a heart attack or angina before the age
of 65 years.
Contraindication
People with known hypertension
Previous myocardial infarction
Ischemic heart disease, peripheral vascular disease
Coronary vasospasm/Prinzmetal’s angina, cardiac
arrhythmias (including Wolff–Parkinson–White syndrome)
Hepatic or renal impairment
Epilepsy,a history of seizures and cerebrovascular accident
or transient ischemic attack.
