REVIEW Headache management: Pract Neurol: first published as 10.1136/practneurol-2015-001167 on 3 July 2015. Downloaded from pharmacological approaches Alex J Sinclair,1,2 Aaron Sturrock,2 Brendan Davies,3 Manjit Matharu4 ▸ Additional material is ABSTRACT be very rewarding for the clinician. The published online only. To view Headache is one of the most common conditions purpose of this article, the first of two please visit the journal online (http://dx.doi.org/10.1136/ presenting to the neurology clinic, yet a linked articles, is to provide an up-to-date practneurol-2015-001167). significant proportion of these patients are overview of the pharmacological manage- unsatisfied by their clinic experience. Headache ment of common headache disorders 1Department of Neurobiology, School of Clinical and can be extremely disabling; effective treatment is (as well as a limited number of non- Experimental Medicine, College not only essential for patients but is rewarding pharmaceutical strategies). of Medical and Dental Sciences, for the physician. In this first of two parts review The University of Birmingham, of headache, we provide an overview of Birmingham, UK THE COMMON PRIMARY HEADACHE 2Neurology Department, headache management, emerging therapeutic DISORDERS University Hospitals Birmingham strategies and an accessible interpretation of In European populations, the annual sex- NHS Trust, Queen Elizabeth clinical guidelines to assist the busy neurologist. Hospital Birmingham, adjusted prevalence for tension-type Birmingham, UK headache is 35%, for migraine is 38%, 3 Department of Neurology, Royal BACKGROUND but for cluster headache is only Stoke University Hospital, ’ 0.15%.45These three together comprise Stoke-on-Trent, UK Headache is listed among the WHO s 4Headache Group, Institute of major causes of disability with a global the most prevalent primary headache dis- Neurology, London, UK prevalence of 47% (symptoms occurring orders. The remaining primary headache — — at least once in the past year). It is the diagnoses all relatively rare include Correspondence to paroxysmal hemicrania, hemicrania con- Dr Alex J Sinclair, Department of commonest neurological syndrome pre- Neurobiology, School of Clinical senting to primary care with 3% of adults tinua, short-lasting unilateral neuralgi- and Experimental Medicine, consulting a general practitioner for head- form headache attacks, hypnic headache College of Medical and Dental 1 and new daily persistent headache. Sciences, The Medical School, ache each year. Women are dispropor- The University of Birmingham, tionately affected (3:1) and its higher Table 1 outlines the features that help to http://pn.bmj.com/ Wolfson Drive, Edgbaston, prevalence among those of working age distinguish these disorders. Birmingham B15 2TT, UK; adds to the socioeconomic burden with Migraine is a common and disabling [email protected] loss of productivity, estimated at £2.25 primary headache disorder and is the 2 Received 21 April 2015 billion per year in the UK. focus of this article. We also briefly con- Revised 13 May 2015 In neurological practice, headache sider the other common primary head- Accepted 6 June 2015 accounts for 25% of new referrals and ache disorders, tension-type headache, on September 28, 2021 by guest. Protected copyright. yet a large proportion of these patients cluster headache and also the manage- feel dissatisfied even if they make it to ment of medication-overuse headache. the neurology clinic, partly due to a reported lack of interest in the disorder MIGRAINE by the reviewing neurologist.2 Most The changing theories of migraine patients with headache have migraine, The vascular hypothesis was central to and when this diagnosis is made it is early understanding of migraine patho- usually correct (98%).3 However, a physiology. Its central premise was that quarter of patients with migraine have as intracranial vasoconstriction caused the their diagnosis missed. Furthermore, of aura, while reflexive secondary vasodila- those identified as a non-migrainous tation generated pain through perivascu- primary headache, 82% actually have lar nerves. However, advances in migraine or probable migraine.3 intracerebral blood flow imaging have To cite: Sinclair AJ, Neurologists consequently see a lot of largely refuted this hypothesis. Sturrock A, Davies B, et al. Pract Neurol Published Online patients with headache and the condition The neurovascular hypothesis posits First: [please include Day is very disabling for individuals. A diagno- that migraine is a disorder of the Month Year] doi:10.1136/ sis, empathy and effective treatment make endogenous pain modulating systems, practneurol-2015-001167 a huge difference to the patient and can particularly the subcortical structures. Sinclair AJ, et al. Pract Neurol 2015;0:1–13. doi:10.1136/practneurol-2015-001167 1 2 REVIEW Table 1 Key clinical features that assist the differentiation of more common headache disorders Trigeminal autonomic cephalalgias Paroxysmal Hemicrania Trigeminal Headache Tension-type headache Migraine Cluster headache hemicrania continua SUNCT/SUNA neuralgia Sex (M:F) 4:5 3:1 5:1 1:1 1:2 3:2 2:3 Duration 30 min to 7 days (episodic) 4–72 h 15–180 min 2–30 min Continuous headache 1–600 s 1–120 s Frequency Episodic or chronic (variable Episodic or chronic (variable 1–8/day >5 daily for more than Continuous headache >1 daily for more than Very variable from rare to daily) from rare to daily) half of the time half of the time frequency Pain type Location Bilateral Unilateral or bilateral Unilateral Unilateral Unilateral Unilateral; V1/V2>V3 Unilateral; V2/V3>V1 Quality Pressing/tightening Throbbing Variable Variable Variable Neuralgiform pain Neuralgiform pain (non-throbbing) Sinclair AJ, Severity Mild to moderate Moderate to severe Very severe Very severe Moderate to very Very severe Very severe severe Migrainous – +++ +/–– +/–– – et al symptoms . Pract Neurol Autonomic features No +/– +++ +++ +++ +++ Sparse Triggers Alcohol (within Cutaneous Cutaneous 30 min) – – –– 2015; Indometacin +/ (as simple analgesic) ± (as simple analgesic) +++ +++ response 0 :1 Based on framework of International Headache Society Classification Criteria. – 13. doi:10.1136/practneurol-2015-001167 Chronic migraine is defined as headache occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month. Chronic cluster headache and paroxysmal hemicrania are defined as headache attacks occurring for more than 1 year without remission or with remission periods lasting less than 1 month. SUNA, short-lasting unilateral neuralgiform headache with cranial autonomic symptoms; SUNCT, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. Pract Neurol: first published as 10.1136/practneurol-2015-001167 on 3 July 2015. Downloaded from from Downloaded 2015. July 3 on 10.1136/practneurol-2015-001167 as published first Neurol: Pract http://pn.bmj.com/ on September 28, 2021 by guest. Protected by copyright. by Protected guest. by 2021 28, September on REVIEW These include diencephalic and brainstem nuclei that also advocates acupuncture an alternative second-line Pract Neurol: first published as 10.1136/practneurol-2015-001167 on 3 July 2015. Downloaded from can modulate the perception of activation of the trige- therapy for migraine. Although there are limited data minovascular system, which carries sensory informa- to support its use in migraines, it is safe, and many tion from the cranial vasculature to the brain. patients have at least considered this before attending Moreover, the involvement of a multisensory disturb- the clinic. A large study comparing acupuncture with a ance that includes light, sound and smell, as well as sham procedure and with standard migraine prophy- nausea, suggests the problem may more broadly lactics found no significant difference between treat- involve central modulation of afferent traffic. Brain ment groups in the number of migraine days, although imaging studies in migraine suggest that subcortical all interventions were effective.6 Furthermore, acu- structures are important causing migraine. Thus, it puncture appears to improve health-related quality of may be considered an inherited dysfunction of life for many chronic migraineurs at relatively low sensory modulatory networks with the dominant dis- cost.7 In many hospitals, the physiotherapy department turbance affecting abnormal processing of essentially offers an acupuncture service, but patients can also normal neural traffic. access it from primary care. Cognitive behavioural therapy with a trained clinical Diagnosis and assessment psychologist may help, particularly combined with The first step is the accurate and positive diagnosis of medication, but there is very limited evidence of effi- migraine; this is usually straightforward. To select the cacy. Many patients understandably have negative most appropriate management, the migraine pheno- thoughts and emotions linked to the headache pain. type needs to be categorised as either episodic (occur- Cognitive behavioural therapy can help to explore ring on fewer than 15 days a month) or chronic these and potentially lessen this burden, thereby also (occurring on more than 15 days a month, for over reducing anxiety. 3 months and with migrainous headaches on at least 8 days a month). The clinician should scrutinise the Acute management of migraine history for sinister features. If there is a strictly unilat-