[GP] Migraine

Question 1

how is a clinical dx of migraine made?

Answer 1

headache lasting 4-72 h

with 2 of:

• unilateral
• throbbing quality
• aggravated by daily activities

with 1 of:

• nausea +/- vomiting
• photophobia
• phonophobia

Question 2

what is the acute mx for migraine?

Answer 2

single agent therapy:
sumatriptan 50-100mg or
paracetamol 1000mg or
ibuprofen 400-600mg

Question 3

what is the preferred rx for acute migraine?

Answer 3

dual therapy: sumatriptan 50-100mg + paracetamol/ibuprofen

Question 4

what can you consider giving during acute attacks of migraine?

Answer 4

anti-emetic e.g. metoclopramide 10mg

Question 5

what are the indications for migraine prophylaxis?

Answer 5

• significant impact on daily life
• acute mx is ineffective / contraindicated
• risk of medication overuse headache

Question 6

what are the prophylaxis options for migraine?

Answer 6

1st line: propanolol 80-160mg daily (alternative: topiramate 50-100mg)

2nd line: amitriptyline 25-75mg

Question 7

• bilateral
• “tight band” headache
• not aggravated by physical activity

dx?

Answer 7

tension headache

Question 8

• regular use of analgesia for ≥3 months
• headache on at least 15 days/month

dx?

Answer 8

medication overuse headache

Question 9

• unilateral
• stabbing, orbital / supraorbital pain
• 15-180 mins
• autonomic features

dx?

Answer 9

cluster headache

Question 10

• unilateral
• temporal headache
• jaw claudication
• visual disturbance (AION)

dx?

Answer 10

giant cell arteritis (temporal arteritis)

Question 11

what do you do if you suspect cluster headache?

Answer 11

consult neurology

Question 12

what are the ix done to diagnose GCA (temporal arteritis)?

Answer 12

ESR - raised

temporal artery biopsy

Question 13

how do you treat tension headache?

Answer 13

lifestyle measures, paracetamol, ibuprofen

do not offer opioids!

Question 14

how do you treat medication overuse headache?

Answer 14

explain dx, lifestyle measures, withdrawal of analgesia

Question 15

how do you treat acute cluster headaches?

Answer 15

acute: SC sumatriptan +/- oxygen therapy

Question 16

what medication is used to prevent cluster headaches?

Answer 16

verapamil

Question 17

what is the treatment for GCA (temporal arteritis)?

Answer 17

• no visual involvement: prednisolone

- visual involvement: methylprednisolone

Question 18

what are red flag features of headaches?

Answer 18

• new, severe headache
• progressive / persistent headache
• morning vomiting
• worse on lying down
• focal neurological signs

Question 19

what differentials can you consider for an acute, severe headache?

Answer 19

VIVID:
V - vascular
I - infection
V - vision threatening (GCA, acute glaucoma)
I - intracranial pressure rasied
D - dissection

Question 20

thunderclap occipital headache, reduced GCS. dx?

Answer 20

SAH

Question 21

temporal headache, jaw claudication, raised ESR. dx?

Answer 21

GCA

Question 22

LP in last 24 h, headache worst in upright position. dx?

Answer 22

low pressure headache

Question 23

what do headache red flags warrant?

Answer 23

urgent neuro-imaging

Question 24

commencement of topiramate in women of child-bearing age requires initiation of what?

Answer 24

reliable contraception