HEADACHE

Question 0

What are the 4 stages of a migraine?

Answer 0

Prodrome - affect/cognition Sx I.e. Tiredness, yawning, mood changes

Aura

• gradual onset 5 minutes but < 1hr
• visual: visual disturbances
• sensory: tingling in one limb/side of face
• aphasia

Headache

• location: unilateral, sometimes bilateral
• quality: throbbing
• duration: 4-72 hours
• worse with activity, N+V, photophobia

Post drome

• sudden movement -> transient headache
• malaise

Question 1

What are the types of headaches?

Answer 1

Primary

• cluster
• migraine
• tension

Secondary

• vascular: HTN, GCA
• Glaucoma angle closure
• neuro: SOL, stroke, meningitis

Question 2

Migraine criteria?

Answer 2

> /= five headaches for 4-72 hours + (N/V or photophobia)

Plus 2 of

• unilateral
• pulsating
• impairs activities of daily living

Question 3

Management of migraines?

Answer 3

1. NSAIDs and antiemetics
2. Triptan (serotonin 5-HT agonists -> constrict BV -> prevent release of pro inflammatory neuropeptidase)
3. If very SEVERE or persistent migraine
   - IV chlorpromazine (dopamine antagonist/typical antipsychotic with SE: prolonged QTc interval)
   - IV fluids and supportive therapy.

Question 4

Migraine prophylaxis? When is it used?

Answer 4

If headaches affects ADLs > 3X per month or there are complications.

Non-pharm

• CBT
• relaxation techniques

Pharm

• verapamil
• amitryptline
• propanolol

Question 5

Complications of migraines?

Answer 5

Persistent migraine
Persistent aura without infarction
Cerebral infarction
Seizures: migraine aura triggered seizures

Question 6

What is a tension headache? What is management?

Answer 6

Bilateral
Non-pulsatile
Without vomiting/head sensitivity movement.

Rx simple analgesia

Question 7

What are features of ICP headaches?

Answer 7

Worse upon waking, lying, bending forward or coughing. 
Vomiting
Papiloedema 
Seizures
Focal neurological deficits

LP contraindicated!

Question 8

What are features of cluster headaches? What Ix? Rx?

Answer 8

Location: unilateral behind eye
Duration: pain max in 10

+/- photophobia, +/- ipsilateral: ptosis, eyelid oedema, tears, runny nose

MRI - exclude secondary causes

Rx

• acute: 100% O2 + triptan intranasal or subcut
• prevention: verapamil

Question 9

What is GCA, Hx? Complications? What is it associated with?

Answer 9

Large vessel Vasculitis of unknown aetiology

NON- SPECIFIC: fatigue, anorexia, wt loss, fever
HEADACHE
JAW CLAUDICATION
VISUAL DISTURBANCE

Associated with PMR

LOSS OF VISION
AORTIC ANEURYSM/DISSECTION

Question 10

Ix, Dx and Rx of GCA?

Answer 10

Ix - ESR, CRP increased
Temporal artery biopsy -> giant cells (unless vision loss stage)

Dx - consider if > 50, if clinical suspicion -> steroids to prevent blindness, definitive Dx with biopsy

Rx

• if visual Sx -> IV methylprednisolone 3 days then PO PRED high dose + PO aspirin low dose
• if no visual Sx -> PO PRED for 2 weeks then wean