paracetamol
ibuprofen
metoclopramide/domperidone 300 mg tab, 2-3 tab/po/12 hourly
500 mg tab, 2 tab/po/6 hourly
2-400 mg tab, 1-2 tab/po/6-8 hourly
10 mg tab, 1 tab/po/6-8 hourly bleeding
nausea
bleeding
dyskinesia Specific treatment Ergot derivatives
ergotamine tartrate



dihydroergotamine*
1 mg tab, 2 tab/po or suppositories/at onset followed by 1 tab every 30 mins, (max 24 hours dose 6 mg, the total max weekly dose is 10 mg)



0.5-1mg/iv/8 hourly as required, (max total dose 10 mg, supervised)
nausea, vomiting, ergotism Triptans
sumatriptan**
50 mg tabs, 1 or 2 tab/po/at onset, repeat in 2 hours, (max 24 hour dose 200 mg)
or
6 mg/sc/at onset, repeat in 2 hours, (max 24 hour dose 12 mg)
or
5-20 mg/nasal spray at onset, repeat in 2 hours, (max 24 hour dose 40 mg)
chest tightness, paraesthesiae, fatigue

* used only in intractable migraine in specialist headache units

** other triptans are equally effective

An alternative cheaper treatment regime is ergotamine, however it should never be used in pregnancy and regular repeated usage is not recommended because of the danger of ergotism, gangrene, and rarely pulmonary fibrosis. Ergotamine is also contraindicated in peripheral and cardiovascular disease. It is important to note that the combined use together of a triptan and ergotamine is also contraindicated. If the patient is not responding to the combination of analgesics and antiemetics then triptans may be helpful

PROPHYLAXIS

Dietary triggers for migraine should be avoided and oestrogen containing contraceptives used with caution. Preventative treatment reduces the frequency, severity and duration of the attacks (Table 15.3). If the frequency is weekly or greater or the attacks are disabling, then those patients may benefit from daily prophylaxis. Medications used in prophylaxis and their dosages and main side effects are outlined below, and the initial treatment duration is for 3-6 months. The most commonly used options include amitriptyline, beta-blockers and sodium valproate. The anticonvulsant topiramate can also be very effective in cases resistant to other medications, but it is more expensive.

Key points

ANALGESIC OVERUSE HEADACHE

These are a group of headaches lasting longer than 4 hours a day which persist for at least 15 days every month for at least 3 months. The term chronic daily headache (CDH) is also used to describe them. These are usually cases of transformed migraine or chronic tension headaches and may affect over 2% of the population in high income countries, most commonly females. These occur mostly as a result of prolonged use of analgesics including simple analgesics, non steroidal anti-inflammatory drugs (NSAIDs), opiates, ergotamine and triptans. Patients typically complain of daily throbbing bilateral headaches which are only transiently and incompletely relieved by increasing doses of medications. Neurological examination is entirely normal.

Management

The management aim is to decrease the frequency, severity and duration of the headaches by complete withdrawal of medication. The patient will need to be encouraged to have a regular life style and avoid caffeine and be specifically educated about the overuse of analgesics. In particular they will need to understand that there will be persisting symptoms including headaches, nausea, agitation and insomnia, particularly during the first two weeks after stopping. Withdrawal for ordinary analgesics, ergotamine and triptans should be carried out abruptly over a period of 24-48 hours. Withdrawal of opioids may take a period of 2-4 weeks. Remission occurs 2-12 weeks after withdrawal. The patient may need interim symptomatic treatment with an antiemetic, NSAIDs and occasionally a brief course of steroids. Underlying anxiety and depression may also need to be treated. Preventive medications include amitriptyline 10-50 mg/po/nocte.

Key points

CLUSTER HEADACHE

This is an excruciatingly severe, unilateral, headache located around one eye and accompanied by local autonomic dysfunction, redness, swelling and watering of the eye. It occurs in high income countries with a frequency of approximately 1/1000. It has its onset mostly in the 3rd and 4th decade and the male female ratio is about 5:1. It receives its name from its tendency to cluster usually 1-3 times daily (can be up to 8 times) for periods of 3-6 weeks or longer at a time with long intervals, sometimes years completely free of attacks. The attacks are brief, lasting between 30-120 minutes, in contrast to migraine which persists for 4-72 hours. Cluster headaches typically occur at the same time in the 24 hour cycle often waking the patient from sleep.

Management

Stopping the acute attacks of pain quickly is critical. These can be well controlled by inhalation via a mask of 100% oxygen @ 7-10 litres/min for 15-20 minutes. Triptans can be successful if used by injections (e.g. sumatriptan 6 mg/sc) or intranasally (sumatriptan 20 mg). Alternatives include zolmitriptan 5 mg orally. They can be repeated once in 24 hours but should be avoided in patients with multiple attacks because of the danger of overuse. Concomitant use of ergot drugs is absolutely contraindicated because of the danger of a stroke. Prophylaxis during a cluster can be helpful with high dose steroids, prednisolone 60 mg/po/daily for 5 days decreasing by 10 mg every 3 days. Long term prevention is indicated for chronic cluster headaches. This includes verapamil 80 mg bd for 2 weeks increasing by 80 mg every 2 weeks to a maximum of 320 mg bd or tds. Avoiding tobacco and alcohol is also important.

Key points

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