Headache

Question 1

Red Flags

Answer 1

New onset headache >55
Known/previous malignancy
Immunosuppressed
Early morning headache
Aggravated by valsalva

Question 2

Migraine w/o Aura - IHS Criteria

Answer 2

≥5 attacks
Last 4-72 hours (3 days)

2 of:
Moderate/severe
Unilateral
Throbbing pain
Worse on movement

1 of:
Autonomic features
Photophobia
Phonophobia

Question 3

Pathophysiology of Migraine

Answer 3

Stress triggers changes in the brain, causing serotonin to be released.
Blood vessels constrict and dilate.
Chemicals including substance P irritate nerves and blood vessels causing pain.

Question 4

Neurophysiology of Migraine

Answer 4

Cortical spreading depolarization
Activation trigeminal vasculature - dilatation of cranial blood vessels
Release of substance P, Neurokinin A, CGRP.

Question 5

Migraine w/ Aura

Answer 5

Aura fully reversible, sensory, motor or language symptoms. (visual aura most common)
Aura duration 20-60 minutes.
Headache follows <1 hour, but aura can occur simultaneously.

Question 6

Migraine Triggers

Answer 6

Mnemonic: CHOCOLATE

Chocolate
Hangovers (Alcohol)
Orgasms
Cheese
Oral contraceptive pills
Lie ins (sleep)
Alcohol
Tumult (noise)
Exercise
Stress

Question 7

Treatment of Migraine

Answer 7

NSAID

Triptans (5HT agonists) - treat at the start of headache

Question 8

Migraine Prophylaxis

Answer 8

More than 3 attacks per month or very severe = consider prophylaxis. (must trial each drug for minimum 4 months)

Propranolol (reduction in migraine frequency)

Topiramate (Carbonic anyhydrase inhibitor (Na/GABA)) - poor SE profile - weight loss, paraesthesia, impaired concentration.

Amitriptyline

Question 9

Autonomic Cephalgia

Answer 9

The trigeminal autonomic cephalgias (TACs) are a group of primary headache disorders characterised by unilateral trigeminal distribution pain w/ assoc ipsilateral cranial autonomic features:

Ptosis
Miosis
Nasal stuffiness
N/V
Tearing
Eye lid eodema

Question 10

TAC (types)

Answer 10

4 main types

Cluster
Paroxysmal hemicrania
Hemicrania continua
SUNCT

Question 11

Cluster Headache

Answer 11

Young
Men > women
Circardian (around sleep) and seasonal variation.
Severe unilateral headache
Alcohol trigger
15-180 mins duration
Frequency: once or twice a day

Question 12

Cluster Headache (treatment + prophylaxis)

Answer 12

High flow O2
SC Sumatriptan 6mg
Steroids

Prophylaxis: Verapamil

Question 13

Paroxysmal Hemicrania

Answer 13

Elderly
Women > men
Severe unilateral headache
Unilateral autonomic headache

10-30 mins duration
1-40 per day
(shorter and more frequent than cluster headache)

Question 14

Paroxysmal Hemicrania (treatment)

Answer 14

Indomethiacin

Question 15

SUNCT

Answer 15

Short lived (15-120s)
Unilateral
Neuralgiaform headache
Conjunctival injections
Tearing

Question 16

SUNCT (treatment)

Answer 16

Lamotrigine

Gabapentin

Question 17

Trigeminal neuralgia

Answer 17

Elderly
Triggered by touch, usually V2/V3
Severe stabbing unilateral pain
1-90 secs duration

Question 18

Trigeminal neuralgia (treatment)

Answer 18

Carbamazepine