QuestionSBA
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Over the counter analgesia, particularly paracetamol is the most common cause of analgesia overuse headache due to its use being relatively unrestricted. It is an important differential to consider in patients presenting with chronic/recurrent headaches. The criteria to consider this diagnosis is the use of the medication on 2-3 days per week and 10 or more days per month for at least 3 months - these episodes are only happening once per week and have the characteristic quality of a migraine
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Analgesia overuse headache
QuestionChoice
The headache experienced in a SAH is often described as a "thunderclap" headache, referring to the sudden onset and severe quality of the pain, which patients often describe as "the worst headache of my life"
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Sub-arachnoid haemorrhage (SAH)
QuestionChoice
Cluster headaches are a rare form of headache disorder compared with migraine and tension headaches. They are most common in younger male patients, and the pain is classically very extreme, acute in onset (comes on to maximal intensity within minutes) and is localised around one eye (which can become red). Episodes are short compared with migraines, with the pain lasting less than 3 hours (compared to migraines which last between 4-72 hours). The patient often experiences restlessness and agitation during episodes due to the intensity of the pain. They are called "cluster headaches" as they tend to occur in clusters, with periods of frequent attacks (can be several attacks per day) interspersed with periods of no headaches, which can even extend for years
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Cluster headache
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Tension headaches tend to occur across the frontal/forehead region, typically bilaterally and do not have the characteristic throbbing/ pounding character of a migraine. They are also not strongly associated with nausea and are not as disabling, with patients usually able to continue with their work/ activity despite the pain
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Tension headache
QuestionChoice
The POUND criteria for migraine highlight the key symptoms of the condition, all of which are being experienced by this patient. The headache is **P**ulsatile in nature, and each episode lasts between 4-72 h**O**urs. The pain is **U**nilateral, associated with **N**ausea +/- vomiting and is significantly **D**isabling for the patient, preventing them from going about their usual daily activities. Patients may also experience a preceding aura, with either visual or sensory symptoms. Generally, migraines are not _fully_ responsive to simple analgesia such as paracetamol and ibuprofen - specific relief can be achieved with the use of an antiemetic and sumatriptan. In patients where migraines are occurring very frequently, prophylaxis can be considered with medications including propranolol or topiramate
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Migraine
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O for hOurs lol
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I'm actually thick
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# Summary

Migraine is a common neurological disorder characterised by recurrent, unilateral, throbbing headaches often preceded by an aura such as visual or sensory symptoms. Migraines can last between 4-72 hours and often result in photophobia and phonophobia. Key signs and symptoms include a unilateral headache, a pulsating character, impairment or worsened by daily activities, and presence of nausea,  vomiting or photophobia. Diagnosis is often based on clinical history, focusing on the presence of an aura. Management strategies include avoidance of triggers, prophylaxis with medications such as Propranolol, Topiramate or Amitriptyline, and managing acute attacks with oral triptans alongside Paracetamol or an NSAID.

# Definition

Migraine is a primary headache disorder characterised by intense episodes of debilitating headaches, usually unilateral and pulsating in nature. Symptoms may be preceded by an 'aura' which manifests as visual disturbances or sensory changes. The pain usually lasts from 4-72 hours and can be accompanied by nausea, vomiting, photophobia, and phonophobia.

# Epidemiology

Migraines are one of the most prevalent neurological disorders worldwide, affecting roughly 12% of the global population. It is more common in women, with a male to female ratio of approximately 1:3, likely related to hormonal influences. The peak incidence occurs between the ages of 30-39.

# Aetiology

The exact cause of migraines is not fully understood, but it is likely a combination of genetic and environmental factors. 

The triggering factors are variable and can include certain foods, changes in weather, stress, hormonal changes, and certain medications such as oral contraceptives.

# Signs and Symptoms

- Aura (usually visual or sensory symptoms preceding the headache)
- Unilateral throbbing headache
- Photophobia and phonophobia
- Nausea and/or vomiting

The International Headache Society criteria for migraine without aura:

| Criteria | Description                                                  |
| -------- | ------------------------------------------------------------ |
| A        | At least five attacks fulfilling criteria B-D                |
| B        | Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) |
| C        | Headache has at least two of the following four characteristics: <br>1. Unilateral location <br>2. Pulsating quality <br>3. Moderate to severe pain intensity <br>4. Aggravation by or causing avoidance of routine physical activity |
| D        | During headache, at least one of the following: <br>1. Nausea and/or vomiting <br>2. Photophobia and phonophobia |
| E        | Not better accounted for by another ICHD-3 diagnosis         |

# Differential Diagnosis

Migraines must be differentiated from other conditions that present with severe headache. Some of these include:

- Tension-type headache: Bilateral, band-like pressure or tightness, not worsened with physical activity, no associated nausea or vomiting.
- Cluster headache: Severe, unilateral, orbital, supraorbital and/or temporal pain lasting 15-180 minutes, occurring up to 8 times a day, associated with autonomic symptoms like ptosis, miosis, lacrimation.
- Subarachnoid hemorrhage: Sudden-onset severe headache, often described as "the worst headache of my life", associated with nausea, vomiting, and possible loss of consciousness.
- Giant cell arteritis: New headache in a person over 50 years, scalp tenderness, jaw claudication, visual disturbances, elevated ESR and CRP.

# Investigations

Diagnosis is primarily clinical, based on the history and examination. 

A headache diary is important to help identify triggers and response to treatment.

If secondary causes of headaches are suspected, further investigations may be warranted, such as neuroimaging (MRI or CT) or blood tests (ESR, CRP for giant cell arteritis).

# Acute Management

- **Avoidance of triggers**: 
  - Identify and avoid potential triggers like certain foods, stress, and poor sleep.
- **Medications for acute attacks**: 
  - **Triptans** (e.g., Sumatriptan) – avoid in patients with ischaemic heart disease.
  - **Paracetamol** or an **NSAID** (e.g., Ibuprofen) can be used in combination with triptans.
  - **Anti-emetics** (e.g., Metoclopramide)
- **Special considerations**:
  - Female patients with migraine with aura should avoid the **combined oral contraceptive pill** due to increased risk of ischaemic stroke.

# Prophylaxis

- Medications:
  - **Propranolol** (contraindicated in asthma).
  - **Topiramate**.
  - **Amitriptyline**.
  - **Candesartan**.
- Injections:
	- Greater Occipital Nerve Block
	- Botulinum Toxin Injection 
- **Newer treatments**:
  - **Rimegepant** (per NICE guidance, May 2023):
    - Used for preventing episodic migraine.
    - Suitable when at least 3 preventive treatments have failed.
    - Indicated for adults with 4-15 migraine attacks per month.

Regular use of acute migraine medications (e.g., triptans, NSAIDs) more than 10-15 days per month can lead to **medication overuse headache (MOH)**.

Patients should be counseled on limiting the use of acute treatments to prevent MOH.

## References

[Click here for NICE Clinical Knowledge Summaries on Migraines](https://cks.nice.org.uk/topics/migraine/)
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A 31-year-old female presents to her GP with headaches. She describes these as "pounding" and located across her temple unilaterally, usually lasting for around 10 hours. These headaches are associated with significant nausea and are quite debilitating - when they occur, she has to take the day off work which is impacting her career progression. She has been taking regular paracetamol and ibuprofen during episodes with only moderate relief. She is having 1 episode per week at present.

What is the most likely diagnosis?
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