Headache - a guide for clinical pharmacists

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An overview on headache, especially migraine, for clinical pharmacists, by Dr Raeburn Forbes MD(Hons) FRCP, Consultant Neurologist

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Headaches – a guide for clinical pharmacists : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Headaches – a guide for clinical pharmacists Dr Raeburn Forbes MD(Hons) FRCP Consultant Neurologist Craigavon Area Hospital http://www.authorstream.com

Headache is very common : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Headache is very common Lifetime Prevalence % Point Prevalence % Rasmussen et al J Clin Epidemiol 1991;44:1147 Random sample 1000 adults, 76% response to structured interview and examination

Most headaches are primary : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Most headaches are primary Primary Tension-type Migraine Cluster Other primary Secondary Neuralgias Infection / trauma / inflammation / tumour

Migraine is most common disabling headache : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Migraine is most common disabling headache Episodic Moderate-severe Throbbing / pulsatile Sensory sensitivity Nausea Photophobia Sonophobia Osmophobia Worse with movement ©Nature Medicine 2002

Lifestyle is important in migraine prevention : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Lifestyle is important in migraine prevention www.migrainenews.co.uk/migraine-7-steps/ Sleep Hydration Exercise Weight management Stress avoidance / management Effective rescue treatment Effective prophylaxis

If lifestyle sorted – try prophylaxis : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com If lifestyle sorted – try prophylaxis Best evidence: Anti-convulsants – valproate / topiramate / gabapentin Beta-blockers – metoprolol / propranolol / atenolol Tricyclics Fair evidence Magnesium Feverfew extract Butterburr extract (Petasites) Poor evidence Sanomigran

Other drugs tested clinically : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Other drugs tested clinically Anti-convulsants Carbamazepine Lamotrigine Vasodilators Verapamil / clonidine / nadolol / timolol / flunarizine

When migraine gets really bad : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com When migraine gets really bad Neuroleptics Chlorpromazine / risperidone / quetiapine Serotoninergic antagonists Methysergide Corticosteroids Occipital nerve blockade Methylprednisolone + bupivicaine Intravenous levetiracetam

New developments : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com New developments Gap junction blockers Tonabersat (prophylaxis) (RCT) CRGP antagonists Telcagepant (RCT) Glutamate antagonists Memantine (observational) Neurostimulators Occipital nerve stimulators (observational) Transcranial magnetic stimulators

Migraine aura : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Migraine aura Visual Sensory Motor Dysphasic Cognitive / amnesic Basilar

Funny headaches I know : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Funny headaches I know Ice-pick headaches Trigeminal neuralgia Hypnic headache Epicranial neuralgias Red ear syndrome Facial migraine

Admitted with headache : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Admitted with headache 6% risk serious disease Migraine Systemic illness headache ASMO (thunderclap) Meningitis / subarachnoid Intracranial hyper and hypotension (NB cerebral tumour – usually seizures)

Is my headache due to a brain tumour? : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Is my headache due to a brain tumour? Only 2% of brain tumour present with headache as their sole clinical feature Focal neurology (seizures / dysphasia/weakness / visual loss) are more common, and headache accompanies these. 13/100,000 / year get brain tumours 4 people in NI each year get brain tumour with headache as sole and persisting feature

Summary : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Summary Headache is universal symptom Most headaches are not serious Migraine is a preventable and treatablke cause of headache 6% of headache admitted to MAU has serious cause Rare treatable headaches exist

More information : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com More information Migraine www.migrainenews.co.uk Clinical examination / neurology journals www.neurologyfeeds.com Copy of this talk www.authorstream.com Neurology patient Information www.forbesmedical.net

Migraine protocol SHSCT : 

www.forbesmedical.net www.neurologyfeeds.com www.authorstream.com Migraine protocol SHSCT Any takers? A&E MAU Medical-neurology OPC Raeburn.forbes at southerntrust.hscni.net

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