Therapeutic Guidelines: Neurology, version 4, 2011
Headache attributed to a substance or its
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age Preventive medication should be continued for a minimum of 3 to
6 months and then tapered and ceased.
Vasodilators such as dihydropyridine calcium channel blockers, nitrates,
The effective dose of amitriptyline varies widely between individuals,
phosphodiesterase type 5 inhibitors (eg sildenafil) and dipyridamole
but is typically in the range of 50 to 75 mg daily. Its efficacy in relief
frequently cause headache. The combined oral contraceptive pill is a
of headache is independent of its antidepressant action. Other tricyclic
well-known cause of migrainous headache, and in some individuals this
antidepressants may be effective, but data are lacking. If amitriptyline
can occur even after years of symptom-free use. Hormone replacement
produces unacceptable adverse effects, nortriptyline or dothiepin can be
therapy can also cause headaches. Idiopathic (benign) intracranial
used. Selective serotonin reuptake inhibitors may not be as effective as
hypertension is an uncommon adverse effect of tetracyclines, but their
wide use for the treatment of acne has resulted in an increasing number
For patients with tension headache and sleep disturbance, depression
of cases. Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly
should be considered. Counselling in conjunction with appropriate
indomethacin, may be associated with paradoxical headache.
antidepressant therapy may be helpful.
Any drug with a possible temporal relationship to persistent or recurring
For patients with tension headache and symptoms of anxiety, counselling
headache should be suspected if no other cause is obvious. The drug
should be ceased in order to determine its possible causal role.
Antiepileptic drugs (eg sodium valproate, gabapentin), acupuncture and
botulinum toxin type A have been advocated for treatment of frequent
tension headache, but evidence supporting their use is limited.
Medication-overuse (rebound) headache can insidiously develop with
prolonged frequent use of the medications used for treatment of acute
headache. It is usually indistinguishable from the primary headache.
The syndrome is not present in every individual who frequently uses
acute medications. It has not been reported in some types of headache
True cluster headache is rare and mainly seen in males; however, the
(eg cluster headache) or in other types of pain where there is frequent
term ‘cluster headache’ is often incorrectly used to refer to migraines
where the attacks occur in cycles. Attacks of cluster headache are much
Medication-overuse headache occurs after the effect of each dose wears
shorter in duration than (untreated) attacks of migraine, and unlike
off, and the resultant headache is suppressed by a further dose. This
migraine the headache does not swap sides between attacks. In cluster
leads to escalating drug use in a futile attempt to control the headache.
headache, the pain is centred around the orbit and is usually accompanied
by unilateral rhinorrhoea, lacrimation or conjunctival congestion.
The list of acute medications implicated is long and includes
Attacks typically last from 15 minutes to 3 hours, recurring in separate
dihydroergotamine, triptans, opioids, most analgesics and caffeine.
bouts, often nocturnally, with 1 to 8 attacks per day for several weeks or
Combination analgesics containing codeine or other opioids are the
months. Cluster headache can sometimes be difficult to distinguish
commonest cause of medication-overuse headache. Frequent use
from paroxysmal hemicrania (see p.9).
of any of these drugs may lead imperceptibly over time to a state of
treatment is to prevent further attacks Prevention of further attacks
Patients may be at risk of medication-overuse headache if they
(see ‘Preventive treatment’, p.7), and is the main focus of cluster
persistently use acute medication on more than 2 to 3 days per week.
A gradual escalation in medication use may be a clinical clue that
(see ‘Bridging treatment’ [p.8] and ‘Acute treatment’ [p.8]).
medication-overuse headache is developing. Patients with headache
requiring more frequent use of medications should be counselled about
their use of acute medications and have a preventive drug added. The
pain-modifying action of preventive drugs can take several weeks
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