Cluster Headache, Migraine and Temporal Arteritis

Question 1

Describe the clinical features of Temporal Arteritis (Giant cell arteritis), what is it caused by? What is it associated with? (10)

Answer 1

• Unilateral or bilateral headache
• New onset headache (70%)
• Pain on mastication (40%)
• Mainly continuous or throbbing
• Scalp tenderness decreased pulsation of temporal vessels
• Generally unwell
• Usually in the elderly, with temporal artery signs
• An intense inflammatory response centred around the arterial internal elastic lamina –primary antibody ?elastin
• Ischaemia and claudication
• Associated with polymyalgia rheumatica

Question 2

What three clinical aspects help diagnose Temporal Arteritis(Giant cell arteritis) (1, 1+2, 1)

Answer 2

A) A new persisting headache
B) At least one of the following:
• Swollen tender scalp artery with elevated ESR or CRP
• Temporal artery biopsy demonstrating arteritis
C) Major improvement within three days of steroid therapy

Question 3

What three diagnostic investigations can be carried out for temporal arteritis? (3)

Answer 3

• Elevated ESR >50mm/h
• Biopsy
• Doppler scanning

Question 4

What is the risk of temporal arteritis? (1)

Answer 4

• 50% have involvement of ophthalmic artery which may lead to blindness

Question 5

What is the management for Temporal Arteritis (1+2, 1)

Answer 5

• Steroids (prednisolone)
  • Visual symptoms –initially 80mg daily
  • No visual symptoms -initially 60mg daily
• Urgent referral to either GMP, rheumatology or ophthalmology

Question 6

What are cluster headaches part of? (1+3)

Answer 6

• Part of Trigeminal Autonomic Cephalalgias(TAC)
• Cluster headaches
• Paroxysmal hemicranias
• SUNCT

Question 7

What is the definition of cluster headaches (4)

Answer 7

• Unilateral pain principally in the
• Ocular, frontal and temporal areas recurring in
• Severe bouts with daily attacks for several months
• Usually with rhinorrhoea and lacrimation –IASP

Question 8

What are the normal prevalence, aetiology and presentations of cluster headaches (6)

Answer 8

• Prevalence 1%
• Males (5:1), aged 18-40 years
• Unilateral
• Throbbing, burning, severe pain. May wake patient from their sleep (alarm clock headache).
• Severity comparable with trigeminal neuralgia
• Associated factors;-lacrimation, rhinorrhoea, conjunctival injection, Horner’s syndrome.

Question 9

What is the general management of cluster headaches? (1+2, 2(4))

Answer 9

-	Prevention:
•	Avoid precipitating factors
•Alcohol
•Caffeine
•	Prednisolone
•	Gabapentin
•	(Verapamil, Lithium, Methylsergide, GON)

Question 10

What is the management of an acute attack of cluster headache? (1,1+2)

Answer 10

• Oxygen 100% 10-12 litres/minute
• Sumatriptan(5HT1 agonist)
• Subcutaneous
• Intranasal

Question 11

What is a migraine? (5)

Answer 11

• Episodic headache usually accompanied by nausea and photophobia
• Duration hours (4-72 hours)
• Pulsating
• Aura (15% patients)
• Triggers (hormonal/relaxation/perfume/stress oestrogen)

Question 12

What is the treatment for migraines? (3)

Answer 12

• Simple analgesia: Ibuprofen & Paracetamol
• 5HT1 agonist -‘triptan’
• Antiemetic (metoclopramide)

Question 13

What are the indications for medical prevention of migraines? What drug free prevention is available? (5)

Answer 13

• Over two per week
• Interferes with daily function
• Patient education –triggers
• Psychological
• TENS/acupuncture intraoral splints etc

Question 14

What medications do not control the pain of migraines? (3)

Answer 14

• Medications do not control the pain:
• Amitriptyline
• β-blocker