Migraine is one of the most common neurological disorders affecting 11-15% of the population. About one third of migraineurs have an initial aura of neurological symptoms, most often a visual scotoma (blind spot).

Research has shown an association between migraine with aura and increased stroke risk, although the aetiology of stroke in migraineurs remains unclear. Possible mechanisms of migraine induced stroke include cortical spreading depression, vascular factors, inflammation, endothelial dysfunction, patent foramen ovale, genetics, oral contraceptive pill use and smoking. Patent foramen ovale is controversial, and based on current evidence, closure of PFO is not currently recommended as treatment for migraines.

On imaging, many migraineurs are found to have white matter changes similar to those seen in patients with stroke. White matter hyperintensities (WMH) are a common finding, and are typically multiple, small, punctate hyperintensities in the deep or periventricular white matter often seen in T2 weighted MRI images. The clinical significance of these changes in migraineurs is still unclear.

The mechanism underlying the increased prevalence of WMH in migraine is also not yet well understood. It has been observed however that cerebral blood flow is significantly lower in migraine with aura subjects with high white matter hyperintensity load.

Given the increased risk for stroke in this patient population, it is important to identify and modify any vascular risk factors such as high blood pressure, smoking, combined oral contraceptive use and lifestyle factors.

Available data suggest that the combined hormonal contraceptive may further increase the risk of stroke in those who have migraine, specifically migraine with aura. In women with migraine with aura who are seeking hormonal contraception, it is suggested against prescription of combined hormonal contraceptives, and the use of non-hormonal contraception or progesterone only contraceptives is the preferred option.

References: Zhang, Parikh, Qian, Migraine and stroke. Stroke and Vascular Neurology 2017;2:160-167

Lantz, Sieurin, Sjolander et al. Migraine and risk of stroke: a national population-based twin study. Brain 2017:140;2653-2662

Sacco, Merki-Feld et al. Hormonal contraceptives and risk of ischaemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and European Society of Contraception and Reproductive Health (ESC). The Journal of Headache and Pain 2017:18:108

Note: Information on this site is not a substitute for professional medical advice

Previously known as primary exertional headache, is a rare headache type precipitated by exertion. It is commonly described as a pulsating headache, on both sides of the head. Primary exercise headache is termed ‘primary’ because it’s not caused by another condition or disorder.

The headache is typically triggered in hot weather or at high altitudes, lasting 5 mins to 48 hours, and is brought on exclusively during or after physical exertion. Interestingly up to 50% of patients with primary exercise headache report that they also have headaches meeting criteria for migraine.

The underlying cause of primary exercise headache is unclear. It is important however that patients with new or never evaluated exercise headache be considered for imaging studies to exclude possible underlying causes such as subarachnoid haemorrhage. Individuals over the age of 50 with risk factors for heart attack should be evaluated for heart disease as a cause for their headache (Cardiac Cephalgia). It has been reported however that up to 80% of exertional headache is primary, with no underlying cause identified.

The good news is that primary exercise headache is often self limiting, which means that it occurs for a period of time, and then stops occurring. This is often in the vicinity of 3-6 months. Given the self limited nature of primary exercise headache, people should be advised to avoid excessive exercise or triggering activities if possible.

In cases where the headache is mild or builds slowly, warming up before exercising, and or an exercise program that begins slowly, and increases in intensity and length over a period of months, may prevent primary exercise headache.

Naproxen or Indomethacin taken 30-60 minutes before exercise may prevent primary exercise headache in some cases. Beta blockers have also been reported to be effective and are alternative options in patients who cannot take NSAIDS. Since primary exercise headache is self limiting, it’s suggested that treatments be discontinued after 6 months for reevaluation of their need.

References: Primary Exertional Headache: Updates in the Literature, Curr Pain Headache Rep Halker, 2013, 17:337

Primary Exercise Headache, American Migraine Foundation, March 3, 2017

Note: Information on this site is not a substitute for professional medical advice 

Hypnic Headache (HH) is a rare primary headache disorder with an age of onset typically more than 50 years old. Women are affected more than men. They are strictly sleep related headache attacks. Because the headaches often occur at the same time at night, they have been called ‘alarm clock’ headaches.

The headaches have to occur at least 10 days of the month and last between 15min and 4 h after awakening the patient from sleep. They are moderate in intensity and may be on both sides, or one side of the head. There are no associated autonomic features (eyelid drooping, eye redness, tearing, nasal stuffiness). Patients may have nausea, light and noise sensitivity. Rising from bed appears to ease the pain.

Hypnic headache like presentation can at times be reported secondary to brain pathology, night time elevated blood pressure, certain blood pressure medications, and obstructive sleep apnea. An MRI of the head, an evaluation for night time elevated blood pressure, and a review of medications, should be considered as part of the evaluation for HH.

Treatment options include a cup of strong coffee at bedtime, lithium and indomethacin have also been described as being effective.

References:Indomethacin-Responsive Headaches. Current Neurol Neurosci Rep (2015), VanderPluym, 15:516

Headaches of the Elderly. Current Neurol Neurosci Rep (2015) Bravo, 15:30

Note:Information on this site is not a substitute for professional medical advice

Research has shown that sexual, physical and emotional abuse create a predisposition to headache.

People suffering with migraine may have experienced abuse in early life. Significant stress occurring early in life may lead to an amplified response to stress later in life. For some, stress is the most important trigger for migraine. Migraine may also be aggravated by the depression and anxiety that so frequently follow abuse.

In managing your care, it is important that your doctor know if you are currently being abused, or have been abused in the past. If the topic of abuse is not openly discussed, the consequences can include failure of medical treatment and a continued cycle of abuse and poor physical and emotional health.

From the perspective of treating your headache, therapies that help with stress management including psychological support may be beneficial.

Talking to a counselor, speaking to an abuse advocate, or calling an abuse hotline is strongly advised. If you are currently in danger, ask for help! Place these calls from a phone where you will be safe from your abuser. If your children are being abused, inform your doctor so that this can be reported to the authorities.

Patient Resources: Sexual assault, domestic or family violence hotline 1800 RESPECT or 1800 737 732 www.1800respect.org.au

References:Abuse and Maltreatment: Their Effect on Headache, Headache 2011, American Headache Society, Schulman MD

Note: Information on this site is not a substitute for professional medical advice

The Occipital Nerve is located in the base of the skull and inflammation or irritation of those nerves may cause a specific type of pain called “occipital neuralgia.” More commonly, however, those nerves serve as a site of onset upon which the pain signals that produce migraine and other types of headache travel. So, Occipital Nerve Blocks (ONBs) aim to suppress the pain signal origins of chronic headache.

Many patients with chronic headache report that their pain arises from the base of the skull and the pain tends to occur on one side or the other and extends forward to involve the temple, the forehead, the eye or some combination of these sites, so ONBs is one way to treat, manage and prevent chronic headaches and migraines.

What can an Occipital Nerve Block treat?

ONBs may treat a variety of headache disorders and have varying indications. The most common indications include:

1. Treating an acute migraine attack for rescue purposes
2. Rapidly suppressing an attack period in cluster headache
3. Weaning patients with medication overuse off of acute pain medications while prophylactic medications are initiated or escalated
4. Repeating ONBs in the treatment of chronic daily headache

The Occipital Nerve Block procedure

The Occipital Nerve Block procedure involves a small needle which is used to inject a solution into the area around the nerves. The composition of the solution contains a local anaesthetic drug and a steroid anti-inflammatory drug.

The procedure typically takes only a few minutes, and patients should have no problem driving afterwards and carrying on with their day.

Occipital Nerve Blocks are safe and well tolerated, and complications are quite rare. Most patients experience head numbness in the distribution of the injected nerve branches. Localised symptoms such as pain or haematoma may occur. Dizziness or blood pressure alterations may occur uncommonly but are transient. Allergic reactions to local anaesthetic have been described but are rare. Corticosteroid injections may be associated with both local and systemic adverse effects, and your headache specialist will advise regarding these potential issues in more detail.

Pain relief can occur within 15 minutes of the block. For those who experience relief, the duration of the therapeutic response varies widely; for days, weeks or even months.

Note: Information on this site is not a substitute for professional medical advice

References: Information for Health Care Professionals, Peripheral Nerve Blocks for Headaches, American Headache Society, Robbins MD et al Occipital Nerve Blocks, Headache, 2010, Rothrock MD

Cluster headache is a severe type of one sided headache. The pain is a searing, stabbing pain, usually behind one eye or at the temple. Cluster Headache is characterized by eye tearing or redness, running of one nostril, sweating or flushing or swelling of the eyelid, these symptoms occurring on the same side of the head as the pain.

Cluster headache attacks are shorter than migraine, lasting between 15 minutes to 3 hours. Typically the attacks occur at predictable times, most commonly in the very early morning between midnight and 3 am, and once again later in the day or early evening.

Cluster pain is severe, and typically there is an inability to lie still. Patients with migraine prefer to lie down in a dark, quiet room, in contrast those with cluster headache will pace and move around, people almost never lie down during a cluster attack.

Cluster attacks come in periods or cycles, during the cycle a person with cluster headaches will have attacks daily. Typical periods of daily attacks are 6-8 weeks in duration. Cluster headache periods often occur 1-2 times per year, or they can skip years.

Episodic cluster headache is the most common type of cluster in which sufferers have runs of daily attacks and then long periods of time with no attacks. A small number of patients will have chronic cluster headache, with a continuing cluster period going on for longer than a year. Most patients with cluster headaches are male, with a 2:1 ratio compared to females.

There are some interesting associations with cluster headaches. The most reliable trigger for a headache is alcohol, in particular beer. About 50% of patients smoke. Sleep apnoea is found in an estimated 30-80% of those with cluster headaches.

The treatment of cluster headaches includes initial relief with steroids taken by mouth or injected to the back of the head, the starting of a daily preventative medication such as Verapamil (a calcium channel blocker blood pressure medication), and an immediate treatment for each attack.

There are new treatments on the horizon including an injectable antibody targeting the pain chemical calcitonin gene related peptide. If you suffer from Cluster Headaches, and would be interested in participating in a trial of this new treatment, please contact either:

Michelle Cybulski, Clinical Research Coordinator on Ph  (07) 3721 1527 or MCybulski@wesleyresearch.com.au or Jacqui on (07)3721 1548

Typical migraine aura occurs before or during migraine and is experienced by about 25% of all migraine sufferers. The experience can be visual, sensory, or result in problems with speaking or word finding.

Visual changes are the most common form of aura, occurring in more than 90% of those migraineurs with aura. There can be spots, zigzags or crescents, flashes of light, or losing sight partially or fully. The shimmering that occurs in aura when vision is obscured is referred to as a ‘scintillating scotoma’, where a scotoma is a blind spot in vision

Sensory changes are the second most frequent form of typical migraine aura. These may consist of tingling or numbness on one side of the face, body, or tongue.

A third form of typical aura results in problems with speech or language, such as being temporarily unable to speak, slurred speech, being unable to find the right word, or using the wrong word to express an idea.

All 3 common types of aura are considered typical if any one of them lasts between 5 minutes to one hour.

One common misunderstanding is that other symptoms signaling an impending migraine represent aura. These symptoms, called a prodrome are indications that a migraine is upcoming, but they do not represent true migraine aura. Precursory symptoms might be feeling irritable, tired, yawning, or having an unexplained change in mood. Some people will become very energetic, and others have trouble concentrating. Nausea, blurred vision, and neck symptoms are other common signs of early or impending migraine. While these symptoms do not represent aura, they can be useful warning signals to prepare for a migraine and initiate possible assistive measures such as drinking fluids, reducing stress, noise, or excessive environmental stimuli.

References: Headache, The Journal of Head and Face Pain, Tepper, 2014

Note:Information on this site is not a substitute for professional medical advice

Migraine affects over 13% of the global population with females 2 times more likely than males (~18 vs 10%) to suffer from the disease.

An individual is said to have migraine if within his/her lifetime there have occurred 5 or more attacks of headache, each lasting 4-72 hours, severe enough to restrict routine daily activity, and accompanied by nausea or light/sound sensitivity.

Only 20-25% of migraineurs experience aura, and in that minority who do there are relatively few who experience aura with each and every attack.

The headache of migraine may not be intense on every occasion; some migraine attacks may involve no headache (aura without headache), and many attacks may involve headache that is mild in intensity and more suggestive of tension type headache than migraine.

The aetiology of migraine is multifactorial and influenced by diet, lifestyle factors, and hormonal changes. Migraine has a clear tendency to run in families and this suggests a strong genetic component.

The risk for the common forms of migraine-migraine with aura and migraine without aura- is increased when a first degree relative has migraine with heritability estimates of 50-65%.

The disorder likely reflects a genetically induced hypersensitivity involving neurons located within the central nervous system. If a genetically primed neuron is triggered by a change in the external environment (eg drop in barometric pressure) or internal environment (eg sudden drop in oestrogen level), that neuron may activate and trigger its neighboring neurons to join in, inducing the pathways in the brain that conduct head pain to produce a migraine attack.

References:

Headache, The Journal of Head and Face Pain, Rothrock, 2008

Note: Information on this site is not a substitute for professional medical advice

Low dose codeine is currently available over the counter (OTC) in pharmacies for consumers to self administer.

Low dose codeine containing medicines are not intended to treat long term conditions, however many consumers do use these products to self treat chronic pain, such as migraine headaches.

In this setting, the potential for abuse and dependence on the drug can occur, there has also been severe adverse health outcomes reported, including liver damage and even death

Based on these significant issues, Australia’s medicine’s regulator, The Therapeutic Goods Administration (TGA) has made the decision that medicines containing codeine will not be able to be sold at pharmacies OTC, and will be available by prescription only from 1 February 2018

Given these changes, consumers should speak to their medical practitioner about why they take codeine, so they are prepared for the change to accessing codeine containing medicines.

Alternative products that are safe and effective for the management of pain are available. Your GP can provide advice on these options. You may also like to begin a discussion with a headache specialist to explore treatment options, in particular a migraine headache management plan.

Note: Information on this site is not a substitute for professional medical advice

New daily persistent headache is a distinct primary headache syndrome. Primary headache disorders are those for which there is no underlying cause that can be identified. The diagnosis requires that the headache has persisted for more than 3 months, without stopping, and it must not be caused by another medical disorder.

Frequently the person can remember the exact day the NDPH started. The condition can mimic chronic migraine, with light and noise sensitivity and or nausea. Or the headache may be more similar to chronic tension type headache. It can occur at any age, though the average age of onset is 35 years old. It is 2-3 times more common in women, than in men.

Up to 30% of people have had a cold or flu like illness before the start of the headache, about 10% report a stressful life event beforehand, and another 10% have had surgery involving the head (but not neurosurgery). 50% of patients however report no triggering event.

It is important for the migraine specialist, when considering this diagnosis, to make sure that the daily headache is not the result of medication overuse headache. If a person is using pain medications of any kind, including over the counter painkillers, more than 2 days a week, the diagnosis of NDPH cannot be made until this overuse of medication stops.

NDPH does not have any known medicine that cures it. Outcome predictions vary. In some cases the condition resolves itself.  If treatment is required, migraine specialists typically use preventative medications that are used for other headache disorders.  These drugs can be effective and most patients with NDPH are able to achieve an improvement of their headache disorder.

References:

New Daily Persistent Headache, Headache, The Journal of Head and Face Pain, 2016, Tepper

Note: Information on this site is not a substitute for professional medical advice.