Headache

Question 1

SNNOOP10 (Red Flags suggesting secondary headache)

Answer 1

Systemic symptoms including fever
Neoplasm in history
Neurologic deficit or dysfunction
Onset of headache is sudden or abrupt
Older age (>50y/o)
Pattern change or recent onset of headache
Positional headache
Precipitated by sneezing, coughing or exercise
Papilledema
Progressive headache with atypical presentation
Pregnancy or puerperium
Painful eye with automic features
Post-traumatic onset of headache
Pathology of immune system such as HIV/immunocompromised
Painkiller overuse or new drug at onset of headache

Question 2

Features of Tension type headache

Answer 2

Bilateral, pressing/tightening, mild-mod pain, not aggravated by routine activities of daily living
no other symptoms
lasts 30mins-7d

Question 3

Features of migraine

Answer 3

Unilateral or bilateral, pulsating/throbbing, mod-sev pain, aggravated by or causes avoidance of routine activities of daily living, other smx (n/v, unusual sensitivity to light or sight, aura), lasts 4-72hrs

Question 4

Features of cluster headache

Answer 4

Unilateral (around the eye or along face), pain location varies, sev to very sev pain, feels restlessness or agitation, other smx (cranial autonomic smx in same side as headache- red, watery,swollen eye. nasal congestion, sweating), lasts 15-180mins

Question 5

Triggers for TTH

Answer 5

Stress
Activities that cause head to be held in position for a long time
Alcohol
Caffeine
Cold/flu or sinus infections
Dehydration
Hunger

Question 6

Common pharm tx for acute headaches

Answer 6

Paracetamol (alone or with caffeine), aspirin, NSAIDs (ibuprofen, naproxen, diclofenac, ketoprofen)

Question 7

Common pharm prophylactic tx for headache

Answer 7

Amitriptyline (1st line), mirtazapine, venlafaxine

Question 8

Non-pharm tx

Answer 8

CBT, relaxation/stress management, physical/occupational therapy, lifestyle modification (incl sleep hygiene), Headache dairy

Question 9

Criteria for medication overuse headache

Answer 9

1) Headache on >= 15d/month in a pt with pre-existing headache disorder

2) Regular overuse of acute and or symptomatic headache drugs for >3months of:
- Ergotamines, opioids, triptans or combi of analgesics on >=10d/month
- Simple analgesics (para, nsaid) on >=15d/month
- Any combi of the above for >=10d/month

3) Headache cannot be better accounted for by another ICHD-3 diagnosis

Question 10

Why is there a vicious cycle for medication overuse?

Answer 10

Take medicine for ST relief –> get rebound headache –> take higher dose –> cycle repeats

Question 11

Red flags to look out for sudden onset of stroke

Answer 11

Numbness, weakness on one side of body
Sudden and severe headache w no apparent cause
Difficulty speaking or understanding
Dizziness, loss of balance/coordination
Vision loss
Seizures or loss of consciousness

Question 12

ICHD3 criteria for episodic migraine

Answer 12

During lifetime, >=5 migraine attacks lasting 4-72hrs

Question 13

ICHD3 criteria for chronic migraine

Answer 13

> 3months
=15 Monthly headache days (either TTH or migraine)
=8 Monthly migraine day

Question 14

Possible acute pharm tx for migraine

Answer 14

-NSAID (1st)
- Triptans
- Ergotamine
- Ditans (costly)
- Gepants (costly)

Question 15

When is triptans recommended?

Answer 15

When OTC analgesics do not work

Question 16

Are triptans or ergotamine preferred?

Answer 16

Triptans due to its better SE profile

Question 17

What adjunct antiemetics can be given?

Answer 17

Metoclopramide (dopamine antagonist) for N/V

Question 18

Criteria for preventative migraine treatment

Answer 18

AHS:
Offered if (per month): >=6d with no disability or >=4d w some disability or >=3d w severe disability
Considered if (per month): 4-5d w no disability or 3d w some disability or 2d w moderate disability

EHF:
Impairs QoL and
1) Attacks cause disability on >=2 days/month and optimised acute therapy does not prevent the above

or

2) Risk of over-freq use of acute therapy and pt is willing to take daily meds

Question 19

What are some medications to prevent migraine attacks?

Answer 19

Antiseizure/antiepileptics
Beta blockers (propanolol, metoprolol)
Anti-CGRP antibodies/Gepants (given SC or IV)

Question 20

How to assess tx efficacy?

Answer 20

Headache diary to track progression before and after tx and identify triggers
Disability assessment (eg. MIDAS- migraine specific)
Adverse effect from medications