headache

Question 1

What are the 2 types of headaches?

Answer 1

Primary, secondary

Question 2

Give examples for primary headaches

Answer 2

Migraine
Tension type headaches
Trigeminal autonomic cephalgias (cluster headaches)

Question 3

What are secondary headaches?

Answer 3

Headaches that are precipitated by another condition/ disorder- local or systemic
Serious causes of secondary headache are uncommon

Question 4

How do you classify primary headaches based on duration?

Answer 4

Short lasting (<4 hours)

Long lasting (>4 hours)

Question 5

Give examples for short lasting primary headaches

Answer 5

cluster headaches

Question 6

Give examples for long lasting primary headaches

Answer 6

Migraine, tension type headaches, medication overuse headaches

Question 7

What 4 red flags suggest secondary headaches?

Answer 7

Age- new onset/ different headache in a person >50 years
Onset- sudden, severe headache (thunderclap)
Systemic symptoms (fever, rash, neck stiffness weight loss, light sensitivity)
Neurological signs- impaired consciousness, confusion, focal neurology, swollen optic discs

Question 8

Draw out the central hypothesis pathophysiology for migraine

Answer 8

you had better have done it

Question 9

Are migraines episodic or chronic?

Answer 9

Either

Question 10

What are migraine signs and symptoms

Answer 10

Unilateral pain- can be bilateral
pulsating pain
moderate/ sever intensity
last hours/ days (usually 4-72 hours)
aggravated by routine physical activity
usually associated with one or more of the following- nausea and/ or vomiting, photophobia and/ or phonophobia

+/- auras

Question 11

What are auras?

Answer 11

Complex array of symptoms reflecting focal cortical/ brainstem dysfunction
gradual evolution: 5-30 minutes (<60 minutes)
Usually precedes a migraine

Question 12

What are symptoms of auras?

Answer 12

expanding Cs
elemental visual disturbance

Question 13

What are the phases of a migraine?

Answer 13

Premonitary- yawning, polyuria, mood changes, irritability, difficulty concentrating, light sensitivity, neck pain
Aura- visual/ sensory (numbness, parasthesia), weakness, speech arrest
Migraine- head and body pain, light sensitivity, nausea/ vomiting
Resolution- rest and sleep
Recovery- mood changes, food intolerance, feeling hungover, can last unto 48 hours

Question 14

What are the two ways in which migraines are managed?

Answer 14

lifestyle changes
pharmacological therapy

Question 15

What are the lifestyle-related treatments for migraine

Answer 15

Avoiding triggers, diet, exercise, sleep, mindfulness

Question 16

What are the two approaches to pharmacological management of migraine

Answer 16

Acute/ abortive- hard and fast, paracetamol, NSAIDS (high dose and soluble), pro kinetics, triptans (5HT 1B/1D/1F receptor agonists)
Long term preventative- >=5 days a month, low and slow with doses till you find the optimal dose

Question 17

What analgesics should be avoided in migraine?

Answer 17

Opiate-based and mixed analgesics

Question 18

Types of migraine preventatives

Answer 18

Beta blockers
Calcium channel blockers
Tricyclic antidepressants
SNRIs
Serotonin antagonists
Anti-convulsants
ACEi/ARBs
Non prescription
Parenteral
CGRP Antibodies – new medications on the block for preventing migraine!

Question 19

Are tension type headaches episodic or chronic

Answer 19

Episodic

Question 20

What are the symptoms of a tension type headache?

Answer 20

Bilateral
Feels like: tight muscles around head an neck, like head is in a vice
Mild/ Moderate
Not aggravated by routine physical activity
No associated symptoms of nausea/ vomiting or photophobia/phonophobia
lasts 30 minutes but can last hours- days

Question 21

How are tension type headaches treated?

Answer 21

Reassurance may suffice in the majority of patients.
Individual attacks can be treated with simple analgesics such as Aspirin or Paracetamol.
Preventative medications rarely required

Question 22

Signs/ symptoms of cluster headaches

Answer 22

Unilateral (ALWAYS)
severe pain
last 15-180 minutes

associated with one/ more of the following ipsilaterally: eyelid oedema, conjunctival redness/ lacrimation, nasal congestion/ rhinorrhoea

can have facial/ forehead sweating, miosis/ ptosis, restlessness

not associated with a brain lesion on MRI

Question 23

How are cluster headaches treated acutely?

Answer 23

Triptan. Nasal or subcutaneous route

High flow oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex

Question 24

What are preventative treatments for cluster headaches?

Answer 24

Verapamil (Calcium channel inhibitor)- Get an ECG first!
Greater occipital nerve block

Question 25

Migraine attack frequency

Answer 25

1-2 attacks per month

Question 26

Cluster headache frequency

Answer 26

1-3 attacks per day can be upto 8, usually occur daily for 2-3 months at a time