Useful link: exeterheadacheclinic.org.uk
Dr Giles Elrington of the National Migraine Centre demonstrates a 3 minute neurological examination to help exclude sinister causes of headache:
Useful link: nationalmigrainecentre.org.uk
Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.
Aura present in around 30% of migraine attacks
Reconsider migraine diagnosis:
- New onset headache in over 50s
- Change in the pattern of long established migraine
- Atypical aura symptoms
- Monocular visual disturbance (consider amaurosis fugax or retinal detachment)
- Red eye (consider angle closure glaucoma)
- Double vision
- Poor balance
- Encourage use of headache diary (paper diary from National Migraine Centre or Migraine Buddy app)
- Manage co existent analgesic overuse if present
- Do not scan for reassurance
- Acute treatment
- Combination of oral triptan + NSAID, or oral triptan+paracetamol
- If first triptan fails, consider alternative preparation and route of administration
- Alternatives include aspirin 900mg with or without antiemetic
- Do not offer opioids
- Consider propranolol or topiramate
- Alternatives include amitriptyline, pizotifen, candesartan
- Do not offer sodium valproate to females of childbearing potential
- Riboflavin 400mg once daily may be effective (patient to source)
- Discuss Botulinum Toxin for Chronic Migraine in the following
- Headache on 15 days per month at least 8 of which are migrainous
- Has had trials of at least three migraine preventatives
- Is not overusing analgesics or triptans
- Able to maintain diary
With reference to gammacore.
Gammacore is a small portable device that can be used to treat severe pain in cluster and migraine headaches. It is a small device which is held against the neck and delivers a low level electric current which improves the pain of cluster headaches. It is a non-invasive vagus nerve stimulator.
NHSE is expanding the use of gamma core as a third line option for cluster headaches after successful trials held over the last two years.
Currently in Cornwall we are working with the neurology team and will hopefully be in a position to adopt the use of this as policy in Septmeber/October 2021.
- App: migrainebuddy.com
Who to refer?
- Uncertainty regarding diagnosis especially with atypical aura/focal symptoms
- Failure to respond to standard acute and preventative therapies
- Chronic migraine for consideration of botulinum toxin injection
Review Date 13/05/2021
Next Review Date 13/05/2022
Author Dr Andrew Sharp / Dr Janine Glazier
Contributor Dr Jonathan Stewart Consultant Neurology RCHT
Version No. 1.0