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Referral and warning signs
When to refer
Refer to higher level (HC4/H/RR) or specialist if: Diagnosis is uncertain. Headaches are refractory to standard acute and prophylactic treatments. Atypical features or red flags suggesting secondary cause. Need for migraine-specific medications (triptans, ergots) or advanced prophylactics. Chronic migraine or medication overuse headache suspected.
Red flags
- Refer to Red Flags for Headache (General Approach - NEU003). Any 'thunderclap' onset, worsening pattern, neurological signs, fever, neck stiffness, new onset >50yrs etc. warrants urgent investigation for secondary causes.
Signs and symptoms
- Moderate to severe headache, often episodic.
- Typically unilateral (one-sided), but can be bilateral.
- Pulsating or throbbing quality.
- Aggravated by routine physical activity.
- Associated symptoms: Nausea, Vomiting, Photophobia (sensitivity to light), Phonophobia (sensitivity to sound).
- Migraine with Aura: Preceded by transient neurological symptoms (aura), usually visual (flashing lights, zig-zag lines, blind spots) but can be sensory (tingling, numbness) or motor. Aura typically develops gradually over 5-20 minutes and lasts <60 minutes.
- Headache duration usually 4-72 hours if untreated.
Risk factors
- Familial factors / Genetic predisposition.
- Female gender (more common after puberty).
- Triggers (variable between individuals): Stress, anxiety, hormonal changes (menstruation, ovulation, oral contraceptives - estrogen), certain foods/drinks (red wine, aged cheese, chocolate, caffeine withdrawal, MSG), skipped meals (hunger), lack of sleep or too much sleep, bright or flashing lights, strong smells (perfumes), weather changes.
Diagnosis
Clinical assessment
Diagnosis is primarily clinical based on characteristic headache features (using criteria like ICHD-3) and associated symptoms, after excluding secondary causes (especially if atypical features or danger signs present). Keep a headache diary can be helpful.
Investigations
- Usually not needed if history is typical for migraine and neurological exam is normal.
- Investigations considered only if atypical features or red flags (see NEU003) are present to rule out secondary causes.
Diagnostic criteria
Based on established diagnostic criteria (e.g., International Classification of Headache Disorders - ICHD): Requires recurrent attacks (usually ≥5) meeting specific criteria for duration, characteristics (unilateral, pulsating, moderate/severe, aggravated by activity), associated symptoms (nausea/vomiting, photo/phonophobia), and exclusion of other causes.
Management
Non-pharmacological management
- Rest in a quiet, dark room during an attack.
- Cold compresses or ice packs applied to head/neck.
- Identify and avoid personal triggers.
- Maintain regular sleep schedule.
- Stress management techniques.
- Regular meals, stay hydrated.
Pharmacological treatment
- Acute Attack Treatment (Abortive Therapy): Treat early.
- - Simple Analgesics: Paracetamol 1g, Ibuprofen 400-800mg, Aspirin 600-900mg.
- - Anti-emetics: Metoclopramide 10mg PO/IM/IV (also aids absorption of analgesics).
- - If severe/unresponsive: Diclofenac 75mg IM.
- - Migraine-Specific Medications (HC4/RR/H level):
- - Triptans: Sumatriptan 50-100mg PO, repeat after 2h if needed (max 300mg/24h). Contraindicated in uncontrolled hypertension, ischemic heart disease, stroke history.
- - Ergotamines: Ergotamine 1-2mg SL/PO at onset, repeat hourly if needed (max 6mg/attack, max 10mg/week). Contraindicated in pregnancy, hypertension, vascular disease. Risk of medication overuse headache.
- Prophylactic Treatment (Preventive Therapy): Consider if attacks are frequent (>3/month), severe, prolonged, disabling, or acute treatments ineffective/contraindicated.
- - First-line options (HC3/HC4): Amitriptyline (start 10-25mg nocte, titrate up to 75mg), Propranolol (start 40mg BD, titrate up to 80mg BD).
- - Other options (Specialist): Sodium Valproate, Topiramate, Flunarizine, Candesartan, Botulinum toxin injections, CGRP monoclonal antibodies.
- Follow specific Ugandan treatment algorithms/guidelines.
Monitoring
Monitor frequency, severity, and duration of attacks (headache diary). Monitor response to acute and prophylactic treatments. Monitor for side effects of medications. Reassess diagnosis if headache pattern changes.
Complications
- Status migrainosus (debilitating attack lasting >72 hours).
- Medication overuse headache (chronic headache due to frequent use of acute treatments).
- Migrainous infarction (stroke occurring during migraine aura - rare).
- Persistent aura without infarction (rare).
- Chronic migraine (≥15 headache days/month for >3 months, with ≥8 days having migraine features).
- Significant impact on quality of life, work, social activities.
Prevention
- Trigger avoidance.
- Lifestyle modifications (regular sleep, meals, exercise, stress management).
- Prophylactic medication for frequent/severe attacks.
Patient education
- Explain migraine as a neurological condition, not just a 'bad headache'.
- Help identify personal triggers and advise on avoidance.
- Teach how to use acute medications effectively (take early in attack).
- Discuss lifestyle adjustments (sleep, meals, stress).
- Explain rationale for prophylactic treatment if prescribed, and importance of adherence.
- Warn about risk of medication overuse headache.
- Provide resources like headache diaries.
Uganda-specific notes
Differentiate migraine from common secondary causes like malaria or hypertension. Simple analgesics and basic prophylactics (Amitriptyline, Propranolol) should be prioritized based on availability. Triptans and Ergots may not be widely accessible or affordable.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 9, Section 9.1.3.1