Headache

Question 1

Red flags for headache?

Answer 1

New onset headache >55

Known/previous malignancy

Immunosupressed

Early morning

Exacerbation by valsalva

Question 2

What is the pathophysiology of Migraine

Answer 2

Vascular and neural influences

Stress tirggers changes in brain causing serotonin to be released

Blood vessels constrict and dilate

Chemicals incl substance P irritate nerves and blood vessels causing inflammation and pain

Question 3

Diagnostic criteria for migraine?

Answer 3

2 of:

• Unilateral pain
• Throbbing type
• Moderate to severe
• Motion sensitivity

1 of:

• Nausea/vomiting
• Photophobia/phonophobia
• Normal examination and no other cause

Question 4

Triggers of Migraine?

Answer 4

Sleep
Dietary
Stress
Hormonal
Physical exertion

Question 5

Non pharmacologic treatment

Answer 5

Avoid triggers
Headache diary
Relaxation/Stress management

Question 6

Pharmacologic treatment

Answer 6

NSAID

Triptans at start of headache eg Rizatriptan, Frovatriptan for sustained release

Question 7

Prophylactic treatments for Migraine (Patients with more than 3 attacks/month)

Answer 7

Propanolol

Topiramate- Carbonic anhydrase inhibitor (Wt loss, paraesthesia, impaired concentration, enzyme inducer)

Amitriptyline (Dry mouth, postural hypotension, sedation)

Question 8

When is imaging indicated in migraine?

Answer 8

If>55, known malignancy or acephalgic (i.e. no headaches)

Question 9

What are trigeminal autonomic cephalgias?

Answer 9

A group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features (Ptosis, miosis, nasal stuffiness, N+V, tearing, eye lid oedema)

Question 10

What are the 4 main types of TCA?

Answer 10

Cluster
Paroxysmal hemicrania
Hemicrania continua
SUNCT

Question 11

Features of cluster headache?

Answer 11

Young patients (30-40)

Severe unilateral headache, 45-90 mins

Question 12

Treatment for cluster headache?

Answer 12

High flow oxygen for 20 mins

S/c Sumatriptan

Steroids -Reduce course over 2 weeks

Verapamil for prophylaxis

Question 13

Features of paroxysmal hemicrania?

Answer 13

Older patients (50-60)

Severe unilateral headache w/ unilateral autonomic features

10-30 mins, far more frequent than cluster.

Question 14

What is SUNCT?

Answer 14

Short lived (15-120 seconds)

Unilateral

Neuralgiaform headache

Conjunctival injections

Tearing

Question 15

Treatment for SUNCT

Answer 15

Lamotrigine

Gabapentin

Question 16

Investigations for new onset unilateral cranial autonomic features

Answer 16

MRI brain and MR angiography.

Question 17

Features of trigeminal neuralgia?

Answer 17

Elderly (>60)

Severe stabbing unilateral pain

1 sec- 90 sec
10-100/day

Triggered by touch usually V2/V3

Question 18

Treatment of trigeminal neuralgia (Medical and surgical)

Answer 18

Medical: Carbamazepine, Gabapentin, phenytoin, Baclofen

Surgical: Ablation v decompression

Question 19

Investigations for trigeminal neuralgia?

Answer 19

MRI Brain if signs on examination, atypical features, poor response to medical treatment or if surgical treatment is being considered.