Headaches and Migraines by AProf Candice Delcourt

In this podcast, we explore the complexities of diagnosing and treating various types of headaches, with a particular focus on migraines and tension headaches. It is emphasized that while the majority of headaches do not indicate serious medical conditions, they remain a leading cause of disability worldwide. The discussion centers around how healthcare professionals can effectively manage headaches to improve patients' quality of life, underscoring the importance of both symptom recognition and appropriate intervention.

The lecture begins with a case study of Josephine, a 35-year-old patient who experiences typical migraine symptoms. Her headaches are marked by a clear pattern, beginning with visual disturbances known as an aura, followed by unilateral throbbing headaches accompanied by nausea. The differential diagnosis process is elaborated, highlighting the importance of understanding the nature of visual disturbances, which can clearly indicate a migraine. Detailed guidance is provided on when to conduct brain imaging, with specific criteria outlined for when caution is warranted, such as age considerations and atypical symptom profiles.

As the conversation shifts to treatment strategies, the lecturer emphasizes timely symptom management. The reasoning behind recommending anti-inflammatory medications, such as aspirin and ibuprofen, as first-line options for acute migraine treatment is discussed, alongside the rationale for combining these with triptans. Additionally, the pitfalls of opioid use in managing headaches are addressed, noting that they can lead to chronic headache patterns rather than providing effective relief.

Preventative strategies are also examined, with the lecturer advocating for long-term management approaches that involve consistent medication usage over several months to assess effectiveness. Various therapeutic options are presented, including beta-blockers and amitriptyline, while emerging treatments, such as monoclonal antibodies and CGRP antagonists, are introduced as significant advancements in migraine management. The importance of lifestyle management — including sleep, diet, and stress balance — is reinforced as a critical component of effective care.

Through a second case study featuring Ruby, a 45-year-old experiencing chronic migraines exacerbated by analgesic overuse, the lecturer illustrates the dangers of frequent medication usage. This case underscores the need for careful management of analgesics to prevent headaches from becoming chronic. The transition to preventative therapies and the adjustment of lifestyle factors are displayed as necessary steps to help patients regain control over their symptoms.

In conclusion, the lecture synthesizes key insights regarding headache management. Recognition of the headache type and symptoms remains essential for accurate diagnosis, while a combination of acute and preventative treatments, along with lifestyle modifications, can significantly enhance patient outcomes. Participants in the lecture are encouraged to ask questions in the Q&A segment, allowing for a deeper dive into complex cases that may arise outside of common treatment frameworks.

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I mean, as James said, we see lots of headaches, I'm sure you also do,

and there are actually things we can do to help our patients and improve their quality of life.

In common headaches are migraines and tension headaches. The vast majority of

headaches do not correspond to a serious pathology, but it's a leading cause of disability.

So non-life-threatening headaches are very common, but they remain disabling and costly.

So let's have a look at a few cases. So the first patient is Josephine.

She's 35 and she has very stereotyped headaches, usually once a month.

And sometimes she gets a little bit of a run of them with several per week.

It usually starts with a disturbed vision blurring in the left eye and a feeling

that the vision from the left eye is bright.

And about 10 minutes after the visual symptoms started, they get better and she has a headache.

She's a bad unilateral throbbing headache.

The headache grows in intensity and she feels nauseated.

If she takes any action, the headache lasts two to four hours and slowly remits

and she feels washed out afterwards.

So I'm sure you have seen some of these patients before. So what is this?

I mean, this very much looks like a migraine.

So someone who has a visual aura first and then develops a headache,

severe headache, unilateral thrubbing associated with nausea.

The nature of the visual disturbance also tells you that it's most likely a

migraine. That's what we will call positive visual disturbance.

So someone described the vision as being bright or zigzags or watery vision,

as opposed to someone who has a stroke who will say, I lost the vision in the right eye.

So there, when you take the history and examine the patient,

one of the things to ask is they try to cover one eye. Is this hemivisual field

or is it happening just in one eye?

So now we talk a bit about what we do and how quickly we should treat and whether

we should do brain imaging.

Before I come to the treatment, I want to just talk about imaging.

When do we do brain imaging? I guess probably as neurologists,

we might be doing more brain imaging than you do. I tend to do a brain imaging

when I see a new patient with headaches, even if it's typical of migraine.

I like having a brain imaging.

And then, obviously, if there is any concerns that it's not a typical headache

or if the typical headache changes.

So things to worry about. When do we worry that can be something else?

So there are a few examples here.

If the patient has a known cancer or systemic condition, you might worry that

this could correspond to a brain metastasis.

Someone over 50 with a temporal pain might worry about giant cell arthritis.

Anyone who has abnormal signs on clinical examination, is there an intracranial process.

I mean, someone who has a new headache over 50 is always someone we would be concerned about.

Tunderclap headaches, which peak in intensity in less than one minute,

very important. We have to think about subarachnoid hemorrhage.

And then other types of headaches related to changes in intracranial pressure,

like whether they have associated pulsatile tinnitus, whether the headache is positional,

whether there are visual changes and papillary dema and clinical examination

should definitely raise possible diagnosis of increased intracranial pressure.

Some other headaches precipitated by Valsalva might make you think about a mass

lesion or carrie malformation.

So there is this acronym which was suggested in one of the journals that neurologists

read, which is called Practical Neurology. So that's a SNOOP acronym.

So these are kind of warning signs.

If you have some of these, you might have to think about the secondary headache

and organized brain imaging.

So what do we do with migraines? Maybe I'll say what I would do.

Like I would give a gram of aspirin or 800 milligram of ibuprofen.

So a big dose of anti-inflammatory as early as the patient has symptoms.

They have to be quick. Take it very quickly for it to be efficient.

If it doesn't work, combining anti-inflammatory with triptan.

Tryptan seems to have a synergic effect.

So just this little schema shows you that tryptan will act on the cranial vasculature

because we think that when someone has the aura,

there is some constriction of blood vessels causing the neurological symptoms,

and then the blood vessels dilates, causing the headaches.

And one of the key things I've put twice on these slides is we should not be

using opioids for headaches.

It just chronifies the headaches and shouldn't be used on a regular basis.

So in terms of preventative management, one of the things about preventative

management is there are different medications we can try.

And we should try them at a good dose for at least two, three months to know if they work.

Sometimes I see patients who take 10 milligrams of N-DEP, which is okay in terms

of dose, but they only take it when they have a headache.

That doesn't work that way. So every single day for at least two,

three months, keeping your headache diary, and we decide if it works or not.

And we'll give a preventative in someone who has four or more days of migraine per month.

So, the recommended drugs are beta blockers such as propanolol.

Now, Candesartan is one of the medications we can also give in migraines.

Anti-epileptic medications, I mentioned the N-depot or amitriptyline for antidepressants.

I actually realized after I sent these slides that I forgot to put botulinum toxin on this slide.

So, we also use Botox for chronic migraines. and the new drugs,

which are the CGRP monoclonal antibody and the Gapins.

Chronic migraine means more than 15 days of migraine per month.

The medications, so the CGRP antagonists, so amgality,

HIV and viepty, which are the most commonly used, or the only one we have actually in Australia,

and botulinum toxin should only be used in patients who have tried at least

three of the conventional medication and have not responded,

have had potentially bad side effects to them, or have given up, or have...

And then it's only if you have tried three of them and they have failed that

you can prescribe these expensive medications or botulinum toxin.

Lifestyle is important and this little schema there is from the American Migraine

Association, which says sleep, exercise, eat, diary and stress.

So try to manage all these things as well as we can, I guess.

And this will help with symptoms. What's also important is for the patients

to try to identify what, for them,

triggers migraines, like some would know that, for instance,

if they sleep a bit late on the weekend,

they will wake up with a migraine.

Sometimes patients will report changes in atmospheric pressure.

Not much we can do about that one, obviously, but they know that they're more

likely to have a migraine.

And keep a migraine diary or use a migraine app is very useful because,

I mean, we might not remember how last month was.

And there might be just slight changes with medications that we forgot about.

In terms of the CGRP antagonists,

so the CGRP is released by the trigeminal nerve arborization and the receptor

is located on blood vessels.

So the monoclonal antibodies this will act against these proteins and the Gepens, which are here,

which you might have not heard much of these.

I never can... Oh, sorry.

Will act directly on the receptor on the blood vessel.

Currently, the only GEPEND that we have in Australia is a NERTIC,

which unfortunately is not reimbursed.

So it's quite expensive. It's about $30 per tablet.

So if you want to take it as a preventative, you have to take it one every second

day, which obviously is a lot of money.

And then it can also be used in the acute phase as an additional tablet.

So it's a maximum of one tablet per day.

I have to say that these new drugs, Mgality, HIV and ViapT, so the monoclonal

antibody have made a huge difference.

I think for patients with chronic headaches, there wasn't that much we could

do. like this was always a bit of a struggle, they would come back to the clinic

and say, I'm not much better.

But these drugs have been very effective with very good tolerance.

So another case, Ruby is 45 and

I chose two women because unfortunately migraine is more common in women.

So she has a 10-year history of migraine without aura, but over the past year,

her migraine attacks have increased from once a month to several times per week.

So she began taking paracetamol and ibuprofen almost daily, and sometimes using

codeine-containing in combination when the pain was severe.

And she now reports more like a dull, daily pressing headache,

often worse with exertion or stress.

Pain is not as bad as her usual migraine, but this is just there all the time.

And on top of that, she sometimes has her usual migraines.

So, I mean, you might already know what this corresponds to,

but this is also one of the big issues we have with people who have migraines or pain in general.

This is the overuse of entalgics.

So patients who tend to use antalgics for more than 15 days per month are at

risk of chronifying their headaches and develop this more like constant duller type of headache.

And it's often hard to tell them that they have to stop taking these antalgics

all the time because they're in pain all the time.

But it has to happen somewhat quickly, if it's just Panadol or ibuprofen,

a bit slower if there is any codeine-based or opioid medication.

And then we will start them on a preventative medication and reinforce all the

importance of sleep hygiene,

stress management, hydration, and awareness about triggers.

So, I mostly talk about these common types of headaches, but I'm happy to answer

a question you might have about other things in the Q&A.

So, just to summarize, headaches are common and treatable.

History is a key to diagnosis and neurological science are rare.

Acute therapy includes simple analgesic and opioids should be avoided.

And if any concerns, we're always happy to see these patients. Thank you.