Diagnosis and Management of Headache

Abstract

IMPORTANCE Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide.OBSERVATIONS Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT 1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT 1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo.CONCLUSIONS AND RELEVANCE Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.

Paracetamol: A Review of Guideline Recommendations

“…Recently, Abdel Shaheed analyzed data from 36 publications and reported that paracetamol produced modest pain relief in hip and knee osteoarthritis, tension headache, and post-craniotomy pain and that it was ineffective in other conditions [ 145 ]; the authors concluded with the need for large, high-quality trials to reduce uncertainty about the efficacy of paracetamol in common pain conditions. In the last few months, new published studies report the safe use of paracetamol in patients with chronic kidney disease [ 147 ], the significant efficacy of paracetamol for post-arthroplasty pain [ 148 ], the lesser efficacy of paracetamol than ibuprofen for post-laminectomy pain [ 149 ], the opioid-sparing effects of paracetamol in the Emergency Department [ 150 ], the recommendations against paracetamol in lumbar spinal stenosis with neurogenic claudication [ 151 ], and the recommendations in favor of paracetamol for postcesarean pain [ 152 ] and for migraine [ 153 , 154 ].…”

A rational approach to migraine diagnosis and management in primary care

“…The main differential diagnoses for migraine are tension-type headache and cluster headache [ 28 ]. Distinguishing features between these headache types include the typical location, quality, severity, and duration of pain, associated symptoms, and typical behaviour during attack, as shown in Figure 2 [ 32 ]. Briefly, tension headaches generally have mild-to-moderate, bilateral pain and lack migraine-associated symptoms (e.g.…”

“…Ditans are selective serotonin 5-HT 1F receptor agonists. In clinical trials as acute treatment, lasmiditan provided more benefit than placebo for freedom from headache pain and other associated symptoms including nausea, photophobia, and phonophobia 2 h after treatment [ 32 ]. Gepants and ditans are not thought to cause vasoconstriction and are not contraindicated in patients with cardiovascular disease or cardiovascular risk factors [ 42 ].…”

“…In two clinical trials, treatment with onabotulinumtoxinA was found to reduce total headache days in patients with CM with or without acute medication overuse [ 46 ]. The mechanism by which onabotulinumtoxinA provides benefit for migraine treatment is thought to involve peripheral inhibition of the release of inflammatory neurotransmitters/peptides [ 32 ].…”

Dietary omega 3 fatty acids for migraine

“…Migraine is one of the most common neurological diseases and affects one billion people globally 1. The past several years have seen the introduction of several new acute and preventive treatments for migraine, but patient and clinician interest in non-pharmacological treatments, including dietary changes, remains strong 23…”