Headache

Question 1

Hemicrania Continua

Features?
Frequency? Duration?
Treatment?

Answer 1

TAC headache - Restless/agitation and/or least 1 autonomic sign (eyelid edema, conjunctival injection, lacrimation, partial Horner’s, rhinorrhea/congestion, ear fullness)
Usually unilateral and severe

Continuous at least 3 months w/ moderate to severe exacerbations.

Indomethacin - trial at high dose. Patient should respond completely within a week

more common in women

Question 2

Paroxysmal Hemicrania

Clinical features?
Frequency? Duration?
Treatment?

Answer 2

TAC headache - Restless/agitation and/or least 1 autonomic sign (eyelid edema, conjunctival injection, lacrimation, partial Horner’s, rhinorrhea/congestion, ear fullness)

At least 20 attacks, lasting 2-30minutes, occur >5 times a day more than 50% of the time

Indomethacin - trial at high dose. Patient should respond completely within a week

more common in women

Question 3

Cluster Headache

Clinical Features?
Frequency and duration?
Treatment?

Answer 3

TAC headache - Restless/agitation and/or least 1 autonomic sign (eyelid edema, conjunctival injection, partial Horner’s, rhinorrhea/congestion, ear fullness)

At least 5 attacks lasting 15-180 minutes, 1-sided severe temporal, orbital, or supraorbital pain, occurring qod - 8x a day at least 50% of the time during a cluster cycle.

Does not respond to Indomethacin.
Acute: Oxygen therapy, rapid triptan (subq or intranasal sumatriptan, intranasal zolmitriptan)
Preventative: “Verapamil +” ….VPA, lithium, melatonin

more common in men

Question 4

Trigeminal Neuralgia

Clinical Features?
Freq and duration?
Treatment?
Dx?

Answer 4

No autonomic features. Not a TAC. Classified as “Painful cranial neuropathy”

At least three attacks of unilateral face pain in trigeminal distribution w/o radiation. At least 3 of: Recurrent, lasts a second to two minutes, severe, shooting/electric/stabbing, precipitated by stimuli like chewing or touch,.

Carbamazepine is first line. Can try gabapentin, topirimate

Bilateral or young woman, evaluate for MS, lyme, sarcoidosis, other secondary causes

Question 5

SUNCT and SUNA

Clinical Features?
Frequency and duration?
Treatment?

Answer 5

Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing
Short-lasting Unilateral Neuralgiform headache with cranial Autonomic symptoms

TAC headaches - Restless/agitation and/or least 1 autonomic sign (eyelid edema, conjunctival injection, partial Horner’s, rhinorrhea/congestion, ear fullness).
1-sided mod-severe temporal, orbital, supraorbital, or trigeminal pain

At least 20 attacks lasting 1-600 seconds either individually or in clusters, at least once daily (usually much more) at least 50% of the time during a cycle.

SUNCT = needs injection and lacrimation. SUNA = can have one or neither of those

Does not respond to Indomethacin. more common in men

Question 6

Hemiplegic migraine
Types, mechanism, and symptoms?
Diagnosis?

Answer 6

Familial (all AD):
1. FHM1 = CACN1A (19p13) - P/Q Ca channel subunit
- +/- cerebellar (nystagmus, ataxia), coma, prolonged hemiplegia, transient cerebral edema or atrophy, but FULL RECOVERY

2. FHM2 = ATP1A2 (1q23) - A1A2 Na/K ATPase channel
   - recurrent coma, frequent/long-lasting hemiplegia, seizures, ID. NO ataxia
3. FHM3 = SCN1A (2q24) - defects in pre- and post-synaptic voltage-gated Na channels

At least 2 attacks w/ aura of fully reversible motor weakness +/- sensory, visual, and/or speech symptoms. Also 2 of following:
A. headache w/ aura or within 60mins of cessation, B. one or more aura symptom that spread over 5 minutes and/or two or more develop in succession, each motor aura lasts <72 hours,

Question 7

Sumatriptan

Use? MoA? Side effects? Contraindications? Metabolism

Answer 7

Seratonin Agonist

Use:
- abortive treatment for migraines (1st line)

Mech of Action:
- increases cerebral artery vasoconstriction, 5HT1B/1D agonist in cerebral vessels, preventing vasodilator release and inhibiting trigeminal nerve activation
- Must be used early in HA for effect

Side Effects:
- Coronary vasospasm
- mild tingling

Contraindications:
- CAD, Prinzmetal’s Angina

Metabolism:
- Half-life <2h

Question 8

Di-hydroergotamine

Answer 8

Ergot Alkaloid

Use:
- abortive treatment for migraines

Mech of Action:
- Partial agonist at vascular α and 5HT2 receptors, causing vasoconstriction of cerebral vessels

Side Effects:

Contraindications:
- do not use within 24 hours of triptans

Metabolism:

Question 9

Eptinezumab
Fremanezumab (Ajovy)
Galcanezumab (Emgality)
Erenumab (Aimovig)

Answer 9

CGRP Monoclonal Abs

• Abortive and preventive therapy
• Erenumab only one that targets CGRP receptor, not ligand (“E aims for the receptor”)