Final Exam -- Headaches--Part I

Question 1

Nearly 90% of headaches fall into one of these categories: migraine, tension-type, chronic daily, and cluster. Which of these types of the most commonly diagnosed?

Answer 1

Migraine

Question 2

Nearly 90% of headaches fall into one of these categories: migraine, tension-type, chronic daily, and cluster. Which of these types of the most frequent?

Answer 2

Tension-type

Question 3

Headache danger signs are symptoms which may indicate a serious underlying cause of the headache. These can be remembered by the acronym SNOOP. What does the S stand for?

Answer 3

Systemic symptoms–fever, weight loss, cancer, immunocompromised, pregnant

Question 4

Headache danger signs are symptoms which may indicate a serious underlying cause of the headache. These can be remembered by the acronym SNOOP. What does the N stand for?

Answer 4

Neurologic symptoms–confusion, impaired consciousness, bilateral optic disc swelling, seizures

Question 5

Headache danger signs are symptoms which may indicate a serious underlying cause of the headache. These can be remembered by the acronym SNOOP. What do the O’s stand for?

Answer 5

Onset is new (especially if over age 40*)

Other associated features–head trauma, drug use, pain worse with posture changes

Question 6

Headache danger signs are symptoms which may indicate a serious underlying cause of the headache. These can be remembered by the acronym SNOOP. What does the P stand for?

Answer 6

Previous headache with history of progression–change in frequency, duration, intensity

Question 7

Besides SNOOP, what are the two headache danger signs mentioned in class?

Answer 7

“First or worst” headache*

Headaches not reponding to treatment

Question 8

If a patient has a danger sign for a headache, imaging should be done, and typically an MRI is preferred over a CT (though CT is preferred in emergencies). Lumbar puncture should be performed if you are suspicious for either of what two conditions?

Answer 8

Meningitis or subarachnoid hemorrhage

Question 9

Migraine headaches affect activities of daily living, are ___________ (unilateral/bilateral) and typically occur how many times per month?

Answer 9

Unilateral, 1-4 times per month or less.

Question 10

There were three types of migraine headaches discussed in class: without aura, with aura, and aura without headache (acephalgic). Which of these is the most common type?

Answer 10

Migraine without aura.

Question 11

Comparing migraine with aura to migraine without aura, which requires at least five attacks for diagnosis?

Answer 11

Migraine without aura.

Question 12

Comparing migraine with aura to migraine without aura, which requires at least two attacks for diagnosis?

Answer 12

Migraine with aura

Question 13

The diagnostic criteria for a migraine without aura includes the headache lasting how long?

Answer 13

4 to 72 hours

Question 14

The diagnostic criteria for a migraine without aura includes a headache with at least two of which four characteristics?

Answer 14

Unilateral location
Pulsating quality
Moderate or severe pain
Aggravation caused by routine physical activity (or headache causing avoidance or routine physical activity).

Question 15

To be diagnosed as migraine with aura, the aura symptom(s) must be fully reversible. Two of what four characteristics must be present?

Answer 15

At least one aura symptoms spreading gradually over more than 5 minutes (and/or two or more symptoms occurring in succession)
Individual aura symptoms last 5 to 60 minutes
At least one aura symptom is unilateral
Aura accompanied by or followed within 60 minutes by a headache

Question 16

The cortical spreading depression (CSD) theory of migraine pathophysiology states that aura are caused by a wave of excitation in parts of the brain. CSD is also said to activate the trigeminal system* and cause release of what neuropeptides?

Answer 16

Calcitonin gene-related peptide (CGRP)*
Substance P
Neurokinin A

Question 17

The cortical spreading depression (CSD) theory of migraine pathophysiology states that aura are caused by a wave of excitation in parts of the brain. The permeability of the blood-brain-barrier is affected by what inflammatory markers?

Answer 17

COX-2, TNF-alpha, MMPs

Question 18

True or false: the cortical spreading depression theory (CSD) states that nociceptor threshold is increased, and the magnitude of their response is increased as well.

Answer 18

False; the threshold is decreased (easier to feel pain), and the magnitude is increased

Question 19

Migraines are associated with depletion of which endogenous substances? With excess of which substance?

Answer 19

Depletion of serotonin and estrogen; excess dopamine.

Question 20

There are lots of possible triggers for migraines. Which three were bolded on the list in class?

Answer 20

Emotional stress, hormones in women, not eating/hunger.

Question 21

A prodrome to a migraine occurs between 24-48 hours prior to the headache and involves what types of findings?

Answer 21

Depression, irritability, food cravings, neck stiffness, yawning, fatigue, difficulty concentrating, aversion to light, sounds, smells.

Question 22

The most common type of aura is visual. It occurs over 5 minutes and may be a zig-zag pattern or a shimmering scintillating appearance. It may be a C-shaped and will leave a central scotoma

Answer 22

Free card.

Question 23

True or false: the typical migraine headache lasts less than a day, is uilateral and involves a throbbing or pulsatile pain.

Answer 23

Mostly true–the duration can be anywhere from 4 hours to several days (so not necessarily “typically” less than a day)

Question 24

____________________ is the perception of pain due to normally non-painful stimuli and can occur with a migraine.

Answer 24

Cutaneous allodynia

Question 25

How would you treat a mild to moderate acute migraine?

Answer 25

NSAIDs or acetaminophen

Question 26

How would you treat a moderate to severe acute migraine?

Answer 26

Triptans or a combination of triptans and NSAIDs

Question 27

How would you treat an extremely severe acute migraine?

Answer 27

Subcutaneous sumatriptan, IV/IM antiemetic with diphenhydramine or dihydroergotamine, IV/IM ketorolac or dexamethasone

Question 28

True or false: narcotics and opioids are good treatment options for acute migraines.

Answer 28

False; they are not recommended.

Question 29

For acute therapy, treatment should start within how long of the onset of the migraine symptoms?

Answer 29

15 minutes

Question 30

Over the counter acute therapy for migraines involves NSAIDs or acetaminophen, or Excedrin (combination of acetaminophen, caffeine, and aspirin). True or false: a large single dose is more effective than multiple smaller doses.

Answer 30

True.

Question 31

Triptans are used to treat acute migraines and are agonists of __________.

Answer 31

Serotonin

Question 32

True or false: when using triptans to treat an acute migraine, they should be taken early on, but not more than 3 times per week*

Answer 32

True.

Question 33

Which triptan is available as a patch?

Answer 33

Sumatriptan*

Question 34

Besides triptan treatment for acute migraines, you can use a triptan/NSAID combo, or dihydroergotamine.

Answer 34

Free card.

Question 35

Which drug for migraines is preferred for anti-emesis?

Answer 35

Metoclopramide*

Question 36

True or false: Prevention of migraines can be done with beta agonists.

Answer 36

False; it can be done with beta blockers.

Question 37

Prevention of migraines can be done with antidepressants like _________ and __________.

Answer 37

Amitriptyline and venlafaxine

Question 38

Prevention of migraines can be done with anticonvulsants like valproate (also used for ________ seizures), lamotrigine (also used for __________ seizures), and topiramate (which has what side effects?).

Answer 38

Valproate: general seizures
Lamotrigine: focal seizures
Topiramate: causes angle closure and myopic shift

Question 39

Prevention of migraines can be done with a calcium channel blocker like _________ .

Answer 39

Verpamil

Question 40

Avoiding triggers of migraines, getting regular sleep, regular meals, and regular exercise, and keeping a headache diary can all help with migraine management. What two other options were listed in lecture?

Answer 40

Acupuncture and transcutaneous electric nerve stimulation (TENS)