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Drug Treatment for Headache Causes of Headaches Vascular Migraine, Hypertension, CVAs Inflammatory Sinusitis, Uveitis, Scleritis, Meningitis

Neoplastic ICSOL, tumours Degenerative Dental caries, Cervical spondylosis Idiopathic/ intoxication Migraine, Cluster, Alcohol, Drugs Congenital Astigmatism, Glaucoma Autoimmune Temporal arteritis, Optic neuritis Trauma Fractures, Orbital trauma, Corneal erosion Endocrine Menstrual, Acromegaly Migraine Unilateral, lasting 4-72h Throbbing Moderate severe intensity Worsens with physical activity Associated with nausea, photophobia, phonophobia Types Classical Migraine Common Migraine With aura Without aura Pathophysiology (mechanisms) Vasogenic theory Neurogenic theory Intracranial vasoconstriction Spreading depression of cortex (during aura phase) Associated with changes in cerebral Rebound dilatation of cranial blood flow vessels during attack Associated inflammation of perivascular tissue Triggers y Food y Sleep changes Neurotransmitters implicated y 5-HT y Neuropeptides Excitability of CNS, Meningeal blood vessel dilation Activation of perivascular sensory trigeminal nerves Vasoactive neuropeptides (calcitonin gene related peptide (CGRP), substance P, neurokinin A) Pain sensitivity Tissue & vessel swelling Inflammation Approach to Migraine Pharmacotherapy Stage Mild Moderate Features Occasional Moderate No functional headaches impairment Some functional impairment Nausea (common) Therapies Mild analgesics Combination Combination analgesics Antiemtics Sumatriptan, Ergot Antiemetics

Types of Headaches Primary (1) Migraine Cluster headache Tension headache Others y Cervicogenic y Post traumatic

Secondary (2) 2 to systemic disease or organic pathology Require treatment of cause

Severe > 3 severe headaches/ month Functional impairment Nausea/ vomiting Sumatriptan, Ergot Prophylactic drug Antiemetics

Migraine Non-specific analgesics Aspirin Paracetamol NSAIDs (eg. Naproxen) Relief from mild headache Effective if taken early during attack Combinations can be used Potential for rebound headache if taken too often Specific serotonergic drugs for acute attacks Serotonergic agonists Ergot alkaloids y Ergotamine y Dihydroergotamine y Sumatriptan Ergotamine (Oral, Sublingual, Rectal, Nasal) Act at 5-HT receptors Combination with caffeine helps absorption Effective when given early during prodrome Adverse Effects y Long lasting generalized vasoconstriction y Nausea, vomiting, diarrhoea Sumatriptan (Oral, Nasal, Subcutaneous) Agonist at 5-HT1D/1B Mediate vasoconstriction (5-HT1D/1B receptors on trigeminal nerve fibres) Release of Vasodilator peptides (CGRP) Multiple doses required (short duration of effect) Adverse Effects y Tingling y Dizziness y Muscle weakness y Neck pain y Injection site reaction y Chest discomfort & pain Contraindication y IHD Prophylaxis 5-HT receptor antagonists Tricyclic antidepressants -adrenergic receptor antagonists MAO inhibitors Calcium channel blockers (Flunarizine, Cinarizine) Anticonvulsants sodium valproate Others Naproxen, Chlorpromazine 5-HT Receptor Antagonists Methysergide (5-HT2 antagonist) y 6 week trial necessary y Adverse effects o Nausea o Vomiting o Diarrhoea o Retroperitoneal fibrosis (prolonged use) Mianserin Pizotifen Cyproheptadine -Adrenergic Receptor Blockers Propranolol, Atenolol, Metoprolol, Timolol y 6-12 weeks trial needed Tricyclic Antidepressants Amitryptiline, Nortryptiline y Effect independent of antidepressant action y 6-12 weeks trial needed y Used commonly in mixed headache y Adverse effects o Anticholinergic effects o Sedation o Weight gain Trigeminal Neuralgia Idiopathic condition Involves 2nd & 3rd divisions of trigeminal nerve Trigger zones/ factors may be present Management Carbamazepine (most effective) Phenytoin (IV if severe acute attack) Other anticonvulsants y Valproate y Lamotrigine y Gabapentin

Cluster Headache Severe unilateral, supraorbital/ temporal pain Male > Female 15-180 minutes Associated with y Conjunctival injection y Lacrimation y Nasal congestion y Rhinorrhoea y Miosis/ ptosis y Facial sweating y Eyelid edema Frequency 1 every alternate day (up to several times a day) Occur in clusters lasts 1-2 months Management Treatment Prevention (for 3-4 weeks) Sumatriptan Corticosteroids Ergot Calcium channel blockers 100% Oxygen Lithium carbonate Sodium valproate Methysergide

Tension Headache Most common type of primary headache Pressing/ tightening pain Non-pulsating, mild moderate intensity Bilateral location No nausea/ vomiting Episodic/ chronic Management Mild Moderate/ Severe Simple analgesics Analgesic combinations Codeine (infrequent)

Chronic Anxiolytics Behavioural therapy Antidepressants (Tricyclics, SSRIs) Frequent use of analgesics can lead to analgesic rebound headache