Dr Anna Andreou

The Headache Centre

Guy’s & St Thomas's NHS Foundation Trust &

Wolfson Centre, King’s College London

Migraines and Other Headaches at Work

Headache CentreGeorge Cruikshank

(1792–1878)

• Headache: Pain in the region of the head and neck

• Where is the pain felt: Meninges and extracranial structures

What is a Headache?

Occipital

• It affects nearly everyone occasionally

• One of the most frequent causes of consultation in both general practise and neurological clinics

• Represents an immerse socioeconomic burden

• The NHS expenditure on all headache disorders is estimated at £250 million per year

• The financial burden of all headache disorders on the UK economy is conservatively estimated at £5-7 billion annually (costs of healthcare, lost productivity through both absenteeism and presenteeism, and disability)

IHS code

Classification

Primary headaches

1. Migraine

2. Tension-type headache

3. Trigeminal autonomic cephalalgias

4. Other primary headache disorders

Secondary headaches

5. Headache attributed to trauma or injury to the head and/or neck

6. Headache attributed to cranial or cervical vascular disorder

7. Headache attributed to non-vascular intracranial disorder

8. Headache attributed to a substance or its withdrawal

9. Headache attributed to infection

10. Headache attributed to disorder of homoeostasis

11.Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structures

12. Headache attributed to psychiatric disorder

Painful cranial neuropathies, other facial pains and other headaches

13. Painful lesions of the cranial nerves and other facial pain

14. Other headache disorders

International Classification of Headache DisordersInternational Headache Society, 3rd Edition , 2018

Tension Type Headache (TTH)

Tension Type Headache (TTH)

• Very common (~60-80%; Women : Men 3:1)

• Pain characteristics: ➢ Bilateral tightness/pressure➢ Mild to moderate➢ Not aggravated by movement➢ Duration: 30 min to several days➢ With or without pericranial tenderness

• No nausea, photophobia and phonophobia

• 3% of the population has chronic TTH ( ≥ 15 days, 6 months)

Tension Type Headache At Workplace

• Usually not disabling, but may be discomfort

• May temporarily affect concertation levels

• Chronic TTH can result in substantial disability and work absence

• If disabling, advise your employees to consult a doctor

• Can be treated with over-the counter analgesics*

Be mindful of Medication Overuse Headache (MOH):Frequent use of painkillers can induce a headache that mimics TTH or migraine (stopping painkillers is an effective treatment of MOH)

Trigeminal Autonomic Cephalalgias

3.1 Cluster headache• 3.1.1 Episodic cluster headache• 3.1.2 Chronic cluster headache

3.2 Paroxysmal hemicrania• 3.2.1 Episodic paroxysmal hemicrania• 3.2.2 Chronic paroxysmal hemicrania

3.3 Short-lasting unilateral neuralgiform headache attacks• 3.3.1 Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

(SUNCT)• 3.3.1.1 Episodic SUNCT• 3.3.1.2 Chronic SUNCT

• 3.3.2 Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)• 3.3.2.1 Episodic SUNA• 3.3.2.2 Chronic SUNA

3.4 Hemicrania continua• 3.4.1 Hemicrania continua, remitting subtype• 3.4.2 Hemicrania continua, unremitting subtype

3.5 Probable trigeminal autonomic cephalalgia

Trigeminal Autonomic Cephalalgias

SUNCTParoxysmal

Hemicrania*Cluster Headache

4 15 30 180

• Duration (min)

• Frequency (attacks/day)

Cluster

Headache

Paroxysmal

Hemicrania*

SUNCT/SUNA/HemicraniaContinua*

0.5 - 8 > 5 3 - 200

Trigeminal Autonomic Cephalalgias

* 100% response to Indomethacin

Cluster Headache (CH)

• 0.2-1% prevalence (As prevalent as Multiple Sclerosis!)

• Previously called “Suicidal Headache”

• Women : Men 1:4.3 [up to 1:2.5]- Diagnosis for cluster headaches can be difficult

• Periodic cluster bouts (usually 4-8 weeks), followed by a Remission period

• 1-8 attacks a day, typically occurring at night and at the same time of the day

• 30% of patients develop Chronic Cluster Headache

Cluster Headache (CH)

• Pain characteristics: The pain of a cluster headache is regarded as one of the worst a person can experience and has been described by female sufferers as worse than childbirth - Previously called “Suicidal Headache”

➢ Excruciating orbital/supraorbital/temporal pain ➢ Unilateral, stabbing-like➢ Duration: 15 min to 3h

• At least one ipsilateral autonomic feature (conjunctival lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial sweating)

• Restlessness, such as rocking or pacing

Cluster Headache Treatment

• Acute Treatments: OxygenSumatriptan injectionSumatriptan and zolmitriptan nasal spraysVagus nerve stimulation

• Preventive TreatmentsVerapamilMethysergideLithiumCorticostereoidsTopiramate

Vagus nerve stimulationGreater occipital nerve blockSphenopalatine ganglion block

Cluster Headache At The WorkplaceAdvice for employers and colleagues: Dealing with a Cluster Headache Attack

• Allow a private room for the patient during an attack (patients experience restlessness, some sufferers cry out or bang their heads in response to the pain)

• Ensure they are safe

• Allow safe storage of specific Cluster Headache treatments: a. Oxygen bottles (high flow oxygen is an effective treatment of Cluster Headache

attacks)b. Sumatriptan injections

• Help your employees to avoid triggers:a. Avoid exposing sufferers to stuffy, warm environmentsb. Drinking alcohol during a cluster period may increase the risk of an attack

Advice for employers and colleagues:

• Understand their severity- Train managers to listen and support staff

• Understand that treatments can cause disabling side effects

• Full-time work may become impossible during a Cluster bout and employers will need to be understanding and flexible:

a. Remain in contact with the employee during a bout of cluster headaches

b. Offer flexible solutions in working hours, days and environment

c. Advice your employee to get a specialist consultation with a headache expert (urgent cluster headache clinic at the Headache Centre, Guy’s and St Thomas’ NHS Trust)

d. Advice your employee to seek out the support of people who understand the condition- Charity: Organisation for the Understanding of Cluster Headaches (OUCH)

Cluster Headache At The Workplace

Migraine

Epidemiology of Migraine

1 lifetime prevalence2 one-year prevalence3 not available period for

prevalence

Five Most Prevalent Conditions of the World

Dental caries (adults) 35%

Tension-type Headache 21%

Migraine 15%

Fungal Skin Disease 13%

Other Skin and Subcutaneous Disease 12%

THE GLOBAL BURDEN

OF DISEASE

2010

Migraine – Common & Disabling Disorder

• Migraine is more prevalent than diabetes, epilepsy and asthma combined

• Research suggests that over 190,000 migraine attacks occur every day in the UK

• More than 75% of migraineurs experience at least one attack each month, and more than 50% experience severe impairment during attacks

“Then a pain pierced his head like he’d neverfelt before, it was as though his scar was on fire –half blinded, he staggered backwards . . . The pain in Harry’s head was so bad he fell to his knees”. Rowling JK 2007. Harry Potter and the Philosopher's Stone

Epidemiology of Migraine in Children

• Migraine occurs in 3-10% of children < age of 12

• 18% of 13-14 years old

• Sex ratio 1:1

* Be mindful of employees with children suffering from migraine

Age Specific Prevalence of Migraine

Migraine - The Disorder

Disorder• Repeated attacks

< 15 days/month: Episodic≥ 15 days/month: Chronic

• Family historyMultigenetic predisposition

• Anxiety and depression are common comorbidities in people with migraine

• Triggers (biology)

Stress-relaxation

Hormonal (women)

Sleep: missing/excess

Missing meals

Weather changes

Chemical (alcohol/GTN/CGRP)

Sensory: light, smells

Medication overuse (painkillers)

Attacks

• Premonitory Symptoms

• Head Pain• Unilateral• Throbbing• Movement worsen

•Aura• 20-30% of migraine patients • Transient neurological symptoms

with a typical behaviour• Aura without headache is not

uncommon

• Sensory sensitivity• Sensitivity to light, noise and smells

• Nausea/vomiting

Migraine - The Attacks

Migraine – More Than a Pain Disorder

Adapted from Blau JN. Lancet 1992; 339: 1202–7

A clinical syndrome characterised by headache with specific features and associated symptoms

StructuralFunctional

BehaviouralEnvironmental

Migraine – A Cycling Disorder with Evolutive Characteristics

Episodic migraine Chronic migraine

• Chronic Migraine affects 2% of the UK population

• Headache occurring on ≥ 15 or more days/month for more than three months

Migraine – a Multisymptom Complex of the Brain

MIGRAINE

photophobia

phonophobia

poor concentration

HEADACHE

nausea/vomiting

aura

fatigue

allodynia

osmophobia

speech difficulties

vertigo

yawning

Migraine – Common & Disabling Disorder

Migraine 52.1%

Alzheimer & Other Dementias (15.8%)

Parkinson (1.4%)

Epilepsy (20.1%)

Multiple Sclerosis (1.2%)

Tension Type Headache (4.1%)

Other Neurological Disorders (5%)

Years Lost due to Disability – Neurological Disorders (WHO)

• Migraine is the leading cause of disability among all neurological disorders (and 7th

among all diseases)

• The estimated proportion of time spent with migraine during an average person’s life is 5.3%

• Migraine/chronic headache is the 2nd most frequently identified cause of short-term absence (47%) for non-manual employees

• It is estimated that the UK population loses 25 million days from work or school each year because of migraine

• Absenteeism from migraine estimated cost in the UK is £2.25 billion per year

• Migraine is estimated to cost the NHS £150 million per year, mostly from the costs of prescription drugs and GP visits

• The financial burden of migraine on the UK economy is conservatively estimated at £3.42 billion per year

Migraine – Socioeconomic Burden

• First-line:• Topiramate; * women; contraception

• Propranolol

• Second-line (per NICE Recommendations):• Acupuncture • Riboflabin

• Other preventives:• Amitriptyline, Great Occipital Nerve Block,

Pizotifen, Venlafaxine, Candesartan, Magnesium citrate, Co-Q10, Valproate, single Transcranial Magnetic Stimulation, Vagus Nerve Stimulation

• BOTOX for chronic migraine

• CGRP system monoclonal antibodies

Migraine Treatments

• Triptans *(sumatriptan (also injectable), zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan and frovatriptan)

• Paracetamol *

• Aspirin *

• NSAIDS *

• Transcranial magnetic stimulation

* Medication overuse headache

Acute Treatments Preventive Treatments

Advice for employers and colleagues:

• Understand migraine’s severity- Migraine is NOT just a headache, it is a disabling neurological condition

• Understand that treatments can cause disabling side effects

• Train managers to listen and support staff

• Offer flexible solutions in working hours, days and environment

• Advice your employee to get a specialist consultation with a headache expert (there are effective treatments at specialised Headache Centres)

• Advice your employee to seek out the support of people who understand the condition: Charity: Migraine Trust

Migraine At The Workplace

Migraine At The WorkplaceAdvice for employees suffering with migraine:

• Help your employees to recognise and avoid migraine triggers, and have a balanced schedule

Good posture, avoiding neck discomfort, eye strain, and adjustable screen brightness

Avoid stress/ advice on coping with stress

Reduce caffeine intake:Caffeine overuse or withdrawal may trigger a migraine-like attack

Maintaining the same sleep patterns every day- maintain circadian patterns

Maintaining the same eating schedule/pattern every day- maintain circadian patterns

Avoid alcohol- common trigger

Exercise regularly- while exercise can exacerbate head pain during an attack, in the long term studies suggest it cn reduce frequency of attacks

A bright environment or fluorescent light can trigger a migraine or exacerbate migraine headache

Avoid smells that can trigger a migraine attack in individuals

Migraine At The Workplace

Advice for employers and colleagues: Create a migraine friendly workplace

Good posture, avoiding neck discomfort, eye strain, and adjustable screen brightness

Reduce stress/ offer advice on coping with stress

Avoid use of fluorescent light- can trigger a migraine or exacerbate migraine headache

Reduce exposure to smells that can trigger a migraine attack in individuals

Discuss with employees their needs and the disabling nature of their condition. Help them remove the stigma of the “invisible pain”

Reduce exposure to noise that can exacerbate migraine headache

Migraine At The Workplace

Advice for employers and colleagues: Create a “migraine escape room”

• Dark (consider green walls- green light was found not to exacerbate the headache neuronal pathway)

• Quiet

• Patients can sleep (effective migraine treatment)

• Patients can safely take their treatment (which may include injectables)

Disabling Headaches At The Workplace –Take Home Message

• There is no cure for headaches but there are effective treatments

• Empower employees to seek treatment and improve their wellbeing

• Reduce stigma associated with disabling headaches in the workplace

• Provide support for those impacted by disabling headaches in the workplace

Useful Tools for Headache at the Workplace

https://www.migrainetrust.org/wp-content/uploads/2019/06/The-Migraine-Trust-Help-at-work.pdf

https://ihs-gpac.org/workplace-initiative/

The Migraine Trust- Help at work

The International Headache Society- Global Patient Advocacy Coalition- Workplace Initiative

European Migraine and Headache Alliance

https://fitforwork.org/blog/cluster-headaches-debilitating-painful-and-little-known/

Fit For Work- Cluster Headaches

https://www.emhalliance.org/