Each of these should be used for a maximum of 15 days per month.
Trigeminal autonomic cephalgia
Trigeminal autonomic cephalgia includes cluster headache, hemicrania continua and paroxysmal hemicranias. These are a group of rare headache disorders that, if suspected, should prompt patient referral to a neurologist for diagnosis and management. All are characterised by:
- a strictly one-sided headache
- with associated (typically ipsilateral) autonomic features, such as tearing, conjunctival injection, ptosis, rhinorrhoea, tinnitus, unilateral facial flushing or sweating.
Cluster headache is one of the most severe pains described, and the patient should be referred urgently so that optimal management can be initiated. If the patient experiences frequent episodes then consider starting verapamil 40 to 80mg three times daily while awaiting specialist review. Acute attacks may respond to subcutaneous sumatriptan, a rizatriptan wafer or intranasal sumatriptan. High-flow oxygen (100% at 12 to 15L/min by non-rebreather mask) can also abort an acute attack.
The strategy to manage a patient with headache and codeine dependence is to diagnose the primary headache disorder and direct appropriate treatment towards this, including preventive medications where appropriate. Medication overuse should be addressed concurrently. Codeine should be weaned over seven to 10 days, with bridging therapy if needed. Lifestyle advice is integral to management in this group of patients. MT